For unbridled spite and anti-African prejudice, packed up in some academic sounding writing, it would be hard to beat Timothy Mah and James Shelton's 'Concurrency revisited: increasing and compelling epidemiological evidence'. Don't worry, it's not in the least bit compelling.
One of the main claims of the article is that the person engaging in concurrent relationships doesn't face as high a risk as all their partners. And this is supposed to explain why another study showed that, although men were five times more likely to report having concurrent relationships than women, women are far more likely to be HIV positive.
The gist of the pro-concurrency argument is that while multiple partnerships alone, even the sort of multiples estimated by those with similar prejudices to Mah and Shelton, do not explain extraordinarily high rates of transmission found in many epidemics, concurrency does explain them.
Concurrency is roughly defined as "overlapping sexual partnerships in which sexual intercourse with one partner occurs between two acts of intercourse with another partner". But because there is little useful evidence about rates of such behavior, in African countries or anywhere else, researchers usually resort to data which bears little application to that (or any other) definition of the word.
Authors promoting the concept as an explanation of high HIV prevalence claim that it is the only possible explanation. However it is not an explanation at all, even if you insist, as the HIV industry does, that HIV is almost always transmitted through heterosexual sex in African countries. It has never been demonstrated that concurrency levels are high where HIV transmission is high or that high levels of concurrency even result in high rates of transmission.
Mah and Shelton proceed to list various pieces of research that show that HIV is probably frequently transmitted non sexually; they just don't see the research as showing this. Earlier researchers 'presumed' that HIV transmission where only one partner in a relationship is infected occurred through extra-marital sex. They generally didn't check and when they did, they chose not to believe anything that didn't fit their prejudices.
People like Mah and Shelton could do with a bit of instruction in basic logic. If you assume the truth of your conclusion and use that as your premise, you will end up with a fallacy. Some of the researchers are even frank enough to use words like 'presume' and 'probably' in their cited remarks. But Mah and Shelton feign complete confidence in their conclusions, despite the high incidence of words like 'appear', 'suggest', 'likely', 'may', etc, throughout their paper.
A recent paper which shows prominent clusters of HIV prevalence around roads does not, as Mah and Shelton wish to suggest, support the concurrency hypothesis. But it is consistent with the hypothesis that infections cluster around health facilities and routes to and from health facilities. However, even after exposure to the many articles they cite in their bibliography, they still adhere to their half baked ideas, finding them "reasonable and salient".
Given their insistence that HIV is almost always transmitted through heterosexual sex in high prevalence countries (though nowhere else), the authors plump for male circumcision as the reason why HIV transmission rates in West Africa have always been far lower than in East and South African countries. This especially weak version of the highly questionable mass male circumcision drive taking place in East and South Africa is said to be 'plausible', which probably shows more about the minds (and scruples) of the proponents than anything else.
Just when you might have thought those tired old arguments had been put out to grass, along come Mah and Shelton to compound them with some even more clapped out considerations. In my next post I'll cover an article which shows that concurrency is not a significant driver of HIV transmission but that multiple partnerships are. And that old chestnut dates back to the days when even experts agreed that HIV wasn't always sexually transmitted. But that's how AIDS billions get spent.
Showing posts with label TB. Show all posts
Showing posts with label TB. Show all posts
Sunday, July 17, 2011
Saturday, July 16, 2011
Presentation at Kilimanjaro Clinical Research Institute
Hordes of articles are appearing right now about some promising results from the use of antiretroviral drugs (ARV) to prevent HIV, as opposed to treating it. This is called pre-exposure prophylaxis or PrEP. But the question is, who will benefit from this use of ARVs, which has mainly been tested on Africans?
ARVs are expensive, despite all the posturing about agreements and deals brokered by Bill Clinton and other notable self-publicists. They are so expensive that few countries with serious HIV epidemics and large scale treatment programs have ever been able to cover more than half of the HIV positive population, at most. Usually coverage is a lot less than half.
The biggest programs in East Africa only include a few hundred thousand people, out of millions infected. But HIV negative populations are many times larger than HIV positive populations. Over 90% of the populations in all the East African countries are HIV negative. How will people be selected for PrEP programs? According to the HIV industry most sexually active Africans are at risk of being infected.
Yesterday I had the pleasure of making a brief presentation about sexual and non-sexual HIV transmission to a group of people who work or study at the Kilimanjaro Clinical Research Institute, part of the Kilimanjaro Christian Medical Center (a powerpoint of the presentation slides is available on the KCRI site). The talk was about my usual concern, the 'behavioral paradigm'. This is the view that HIV is almost always transmitted through heterosexual sex in high prevalence African countries.
This 'paradigm' is not based on evidence. In fact, it is frequently contradicted, especially by UNAIDS's own data. But as the flagship of the AIDS industry, this means that resulting UN policy is almost entirely based on what amounts to an extremely racist view. How will that racism, which so far has resulted in a lot of money being spent on large-scale finger-wagging exercises, affect the rollout of PrEP?
One of the slides I used at the presentation was a screenshot of the mathematical model used to back up the industry's claim that most Africans are at risk of being infected with this difficult to transmit virus. The 'Modes of Transmission Survey' for Kenya, for example, suggests that 44% of the 1.5 million HIV positive people were infected by ordinary heterosexual sex. And members of other groups that would be considered to be at low risk in non-African countries are also mysteriously infected in huge numbers.
UNAIDS' argument for this is somewhat circular because the claim that members of the largest group of HIV positive people are infected by their regular partner is supported by the idea that most regular partners have, or at one time had, 'unsafe sex'. But these are just more assumptions based on the behavioral paradigm, not pieces of data that might support it.
It's hard to know whether this adherence to the behavioral paradigm is going to blow up in the industry's face, or whether it will just feed their ongoing demand for profits at any cost. If virtually every sexually active person in a population is at risk, will they all be offered PrEP? Or are UNAIDS going to claim that PrEP is not appropriate for groups that have been considered to be at high risk up to now?
There is also a problem right now about funding ARVs for people who would die without them. Who will stump up tens of times more funding for drugs for people who will not die without them, probably won't benefit from them at all and may even be harmed by them? If saving the lives of some HIV positive people is not considered worth the effort, is it worth the cost and effort to play around with the lives of huge numbers of people just so pharmaceutical companies can become even richer than they already are.
My worry is not just about the use of drugs to reduce HIV transmission. My worry is about the serious lack of clarity about why certain people, mostly Africans, are so susceptible to a virus that is difficult to transmit sexually, yet so many are infected. Simply throwing a lot of drugs at the problem is unlikely to make it go away. This problem needs to be explained without the use of the thoroughly discredited behavioral paradigm.
[For more about pre-exposure prophylaxis, see my other blog.]
ARVs are expensive, despite all the posturing about agreements and deals brokered by Bill Clinton and other notable self-publicists. They are so expensive that few countries with serious HIV epidemics and large scale treatment programs have ever been able to cover more than half of the HIV positive population, at most. Usually coverage is a lot less than half.
The biggest programs in East Africa only include a few hundred thousand people, out of millions infected. But HIV negative populations are many times larger than HIV positive populations. Over 90% of the populations in all the East African countries are HIV negative. How will people be selected for PrEP programs? According to the HIV industry most sexually active Africans are at risk of being infected.
Yesterday I had the pleasure of making a brief presentation about sexual and non-sexual HIV transmission to a group of people who work or study at the Kilimanjaro Clinical Research Institute, part of the Kilimanjaro Christian Medical Center (a powerpoint of the presentation slides is available on the KCRI site). The talk was about my usual concern, the 'behavioral paradigm'. This is the view that HIV is almost always transmitted through heterosexual sex in high prevalence African countries.
This 'paradigm' is not based on evidence. In fact, it is frequently contradicted, especially by UNAIDS's own data. But as the flagship of the AIDS industry, this means that resulting UN policy is almost entirely based on what amounts to an extremely racist view. How will that racism, which so far has resulted in a lot of money being spent on large-scale finger-wagging exercises, affect the rollout of PrEP?
One of the slides I used at the presentation was a screenshot of the mathematical model used to back up the industry's claim that most Africans are at risk of being infected with this difficult to transmit virus. The 'Modes of Transmission Survey' for Kenya, for example, suggests that 44% of the 1.5 million HIV positive people were infected by ordinary heterosexual sex. And members of other groups that would be considered to be at low risk in non-African countries are also mysteriously infected in huge numbers.
UNAIDS' argument for this is somewhat circular because the claim that members of the largest group of HIV positive people are infected by their regular partner is supported by the idea that most regular partners have, or at one time had, 'unsafe sex'. But these are just more assumptions based on the behavioral paradigm, not pieces of data that might support it.
It's hard to know whether this adherence to the behavioral paradigm is going to blow up in the industry's face, or whether it will just feed their ongoing demand for profits at any cost. If virtually every sexually active person in a population is at risk, will they all be offered PrEP? Or are UNAIDS going to claim that PrEP is not appropriate for groups that have been considered to be at high risk up to now?
There is also a problem right now about funding ARVs for people who would die without them. Who will stump up tens of times more funding for drugs for people who will not die without them, probably won't benefit from them at all and may even be harmed by them? If saving the lives of some HIV positive people is not considered worth the effort, is it worth the cost and effort to play around with the lives of huge numbers of people just so pharmaceutical companies can become even richer than they already are.
My worry is not just about the use of drugs to reduce HIV transmission. My worry is about the serious lack of clarity about why certain people, mostly Africans, are so susceptible to a virus that is difficult to transmit sexually, yet so many are infected. Simply throwing a lot of drugs at the problem is unlikely to make it go away. This problem needs to be explained without the use of the thoroughly discredited behavioral paradigm.
[For more about pre-exposure prophylaxis, see my other blog.]
Wednesday, June 22, 2011
Sometimes Targets of Prejudice Embrace that Very Prejudice Themselves
It's odd sometimes how the targets of a prejudice embrace that very prejudice themselves. UNAIDS' prejudice about HIV almost always being transmitted sexually in African countries is a case in point. Academic articles and press coverage alike, explicitly or tacitly, assume the truth of the prejudice. And people here say 'we' or 'Kenyans' or 'Africans' like sex, have a lot of sex or prefer 'unsafe' sex.
In an article about adult male circumcision in Uganda, carried out with the aim of reducing HIV transmission (from females to males), Robert Kalumba warns that many people, male and female, seem convinced that the operation protects everyone from both infection and transmission. This is not the case, although the warning is nothing new.
But he also claims that "Ugandans love sex a lot" and it's hard to know what that means, aside from being an echo of the oft expressed prejudice. HIV prevalence is low in some parts of Uganda, high in others, low in some demographic groups and high in others. Do all Ugandans love sex? More than non-Ugandans? What about in places where HIV prevalence is low? What about non-Ugandans among whom HIV prevalence is far higher than it is in Uganda, such as Swaziland?
Kalumba also embraces the reflex about HIV being related to 'ignorance', just as others say that HIV is 'driven' by poverty. Neither of these reflexes are borne out by the evidence. HIV rates in high (and medium) prevalence countries are, in general, higher among those who have a higher level of education and are wealthier. And the effect is usually stronger among women than men.
Of course, lack of education and poverty are undesirable. The continued appalling educational, health and economic circumstances in developing countries is repugnant; but not because of their relation or lack of relation to HIV prevalence. Rather, HIV is repugnant because it is a virulent disease, one that spreads most readily among people who already face many other problems, such as low levels of access to adequate health facilities.
What Kalumba should be asking about mass male circumcision campaigns is why so much money and attention is going towards an operation which will only benefit some people, all men, when so many others are in even greater need, more often women than men. In fact, any effect in the field may prove small or even negative.
The United Nations General Assembly Special Sitting (UNGASS) report for Uganda in 2009 also makes one wonder to what extent HIV is sexually transmitted. A quick look at their graphs for HIV on the one hand and other recognized sexually transmitted diseases on the other shows that infection patterns are completely different.
Many would suspect that HIV is only partly sexually transmitted. And if they do, they will recognize that circumcision and other measures that assume the truth of the above mentioned prejudice will never be enough on their own.
While he is at it, Kalumba and others could take a look at various data from the Ugandan Demographic and Health Survey, which show that the highest figures for 'unsafe' sexual behavior are those for men, whereas the highest figures for HIV are for women. If he looks at the Aids Indicator Survey, he will notice many other anomalies, such as the number of people who are infected with HIV when they have never had sex, rarely had sex, only had sex with their partner or rarely had 'unsafe' sex.
The fact that some of the richest and most powerful HIV related institutions agree that HIV is almost always sexually transmitted in Africans does not make it so. And people like Kalumba need to be able to spot a prejudice for what it is. Because if Africans don't reject the prejudice, policy for HIV 'prevention' in Africa will continue to fail. You can't eliminate non-sexual transmission of HIV by targeting people's sexual behavior, especially among those who are not even sexually active.
In an article about adult male circumcision in Uganda, carried out with the aim of reducing HIV transmission (from females to males), Robert Kalumba warns that many people, male and female, seem convinced that the operation protects everyone from both infection and transmission. This is not the case, although the warning is nothing new.
But he also claims that "Ugandans love sex a lot" and it's hard to know what that means, aside from being an echo of the oft expressed prejudice. HIV prevalence is low in some parts of Uganda, high in others, low in some demographic groups and high in others. Do all Ugandans love sex? More than non-Ugandans? What about in places where HIV prevalence is low? What about non-Ugandans among whom HIV prevalence is far higher than it is in Uganda, such as Swaziland?
Kalumba also embraces the reflex about HIV being related to 'ignorance', just as others say that HIV is 'driven' by poverty. Neither of these reflexes are borne out by the evidence. HIV rates in high (and medium) prevalence countries are, in general, higher among those who have a higher level of education and are wealthier. And the effect is usually stronger among women than men.
Of course, lack of education and poverty are undesirable. The continued appalling educational, health and economic circumstances in developing countries is repugnant; but not because of their relation or lack of relation to HIV prevalence. Rather, HIV is repugnant because it is a virulent disease, one that spreads most readily among people who already face many other problems, such as low levels of access to adequate health facilities.
What Kalumba should be asking about mass male circumcision campaigns is why so much money and attention is going towards an operation which will only benefit some people, all men, when so many others are in even greater need, more often women than men. In fact, any effect in the field may prove small or even negative.
The United Nations General Assembly Special Sitting (UNGASS) report for Uganda in 2009 also makes one wonder to what extent HIV is sexually transmitted. A quick look at their graphs for HIV on the one hand and other recognized sexually transmitted diseases on the other shows that infection patterns are completely different.
Many would suspect that HIV is only partly sexually transmitted. And if they do, they will recognize that circumcision and other measures that assume the truth of the above mentioned prejudice will never be enough on their own.
While he is at it, Kalumba and others could take a look at various data from the Ugandan Demographic and Health Survey, which show that the highest figures for 'unsafe' sexual behavior are those for men, whereas the highest figures for HIV are for women. If he looks at the Aids Indicator Survey, he will notice many other anomalies, such as the number of people who are infected with HIV when they have never had sex, rarely had sex, only had sex with their partner or rarely had 'unsafe' sex.
The fact that some of the richest and most powerful HIV related institutions agree that HIV is almost always sexually transmitted in Africans does not make it so. And people like Kalumba need to be able to spot a prejudice for what it is. Because if Africans don't reject the prejudice, policy for HIV 'prevention' in Africa will continue to fail. You can't eliminate non-sexual transmission of HIV by targeting people's sexual behavior, especially among those who are not even sexually active.
Tuesday, June 14, 2011
Reducing Maternal HIV: the Only Acceptable Way of Reducing Pediatric HIV
The received view of HIV in high prevalence countries, especially African countries, is that roughly 80% is transmitted through heterosexual sex and most of the remaining 20% is transmitted from mother to child. So it's not surprising that the HIV hierarchy should target mother to child transmission, or at least talk about doing so. Even if the 80% estimate is way out, a very large number of children are infected during pregnancy, delivery or shortly after birth.
While no one could object to aiming to eliminate mother to child transmission, some might wonder if any effort will be made to prevent HIV in pregnant women. That might seem stupidly obvious but I don't see attempts being made to establish why so many pregnant women become infected with HIV, especially late in their pregnancy, or even shortly after birth.
Of course, transmission of sexually transmitted infections (STI) occur as a result of unprotected sex, as does pregnancy. But many of the women infected with HIV are not also, or not as much infected with more common and easier to transmit STIs. http://www.plusnews.org/report.aspx?ReportID=92664 Perhaps more strikingly, many women who are infected with HIV don't have HIV positive partners. And in a lot of cases, there is no routine follow up and testing of partners in African countries, so we can't always even be sure.
Although there is always the assumption that women who are infected shortly before, during or after their pregnancy are infected by their partner as a result of unprotected sex, there is a good chance that many women are not being infected by their partner, nor even through unprotected sex. UNAIDS' insistance that 80% of transmission in African countries is through heterosexual sex is, after all, not based on evidence. It is, on the whole, an unsupported assumption.
Something even better than preventing mother to child transmission, then, is preventing HIV in mothers. And where sexual partners are not even HIV positive, there is good reason to establish just how women are infected, and then use the resulting data to adjust the 80% figure. HIV transmission through some unknown route is very unlikely to be prevented. And that makes prevention of mother to child transmission a lot more difficult to effect.
In countries such as Libya and Romania, where massive rates of HIV transmission were recognized (and acknowledged) to have occurred through unsafe medical practices, many of the children infected went on to infect their mothers through breastfeeding, as opposed to the other way around. But such modes of transmission need to be recognized (and adknowledged) before they will be investigated, let alone prevented.
Recognizing non-sexual transmission would have another benefit: it would reduce stigma. If HIV positive Africans are told that it is almost certain that they were infected sexually, they will be stigmatized. Especially if it turns out that their partner is not infected. Allowing the possibility that HIV can be transmitted in other ways, which it most certainly can, could save a lot of marriages and lives, even the lives of children at risk of becoming infected.
There is some recognition that the state of public health facilities has direct consequences for the health of the people using those facilities. A lack of drugs, equipment and trained personnel has a negative impact on goals such as reducing child and maternal mortality, HIV transmission, malaria and other diseases.
Apparently, drugs and equipment can be stolen or may never reach health facilities. Sometimes patients have to bring the latex gloves and other equipment that will be used for their care. Perhaps sometimes equipment in short supply is reused, even without proper sterilization. But accepting that it can happen is not enough. It also needs to be established if this is contributing to transmission of diseases, such as HIV, and if so, how big this contribution is.
It's all very well to talk/write about destigmatization. But many of those doing the talking/writing are also doing the stigmatizing. There is plenty of evidence that HIV is not always transmitted sexually in Africa and there is evidence that possible cases of non-sexual transmission need to be investigated. Admitting this would go a long way towards reducing transmission, and also reducing stigmatization.
You will no more reduce stigmatization by saying 'stigma is bad' than you will influence sexual behavior by saying 'unprotected sex is risky'. We have learned that through many years of failing to have much impact on HIV transmission. The issue of stigma is very much in the hands of the people who warn us about how damaging it is, the UN, UNAIDS, WHO, CDC, the World Bank, etc.
The best way to reduce HIV transmission is to be clear about how the virus is being transmitted and not to depend on out of date and inappropriate figures. The best way to reduce mother to child transmission is to reduce the number of mothers being infected. And the best way to reduce stigma is to be honest about HIV transmission: we know that it is not always transmitted sexually and we don't even know how much is transmitted sexually.
While no one could object to aiming to eliminate mother to child transmission, some might wonder if any effort will be made to prevent HIV in pregnant women. That might seem stupidly obvious but I don't see attempts being made to establish why so many pregnant women become infected with HIV, especially late in their pregnancy, or even shortly after birth.
Of course, transmission of sexually transmitted infections (STI) occur as a result of unprotected sex, as does pregnancy. But many of the women infected with HIV are not also, or not as much infected with more common and easier to transmit STIs. http://www.plusnews.org/report.aspx?ReportID=92664 Perhaps more strikingly, many women who are infected with HIV don't have HIV positive partners. And in a lot of cases, there is no routine follow up and testing of partners in African countries, so we can't always even be sure.
Although there is always the assumption that women who are infected shortly before, during or after their pregnancy are infected by their partner as a result of unprotected sex, there is a good chance that many women are not being infected by their partner, nor even through unprotected sex. UNAIDS' insistance that 80% of transmission in African countries is through heterosexual sex is, after all, not based on evidence. It is, on the whole, an unsupported assumption.
Something even better than preventing mother to child transmission, then, is preventing HIV in mothers. And where sexual partners are not even HIV positive, there is good reason to establish just how women are infected, and then use the resulting data to adjust the 80% figure. HIV transmission through some unknown route is very unlikely to be prevented. And that makes prevention of mother to child transmission a lot more difficult to effect.
In countries such as Libya and Romania, where massive rates of HIV transmission were recognized (and acknowledged) to have occurred through unsafe medical practices, many of the children infected went on to infect their mothers through breastfeeding, as opposed to the other way around. But such modes of transmission need to be recognized (and adknowledged) before they will be investigated, let alone prevented.
Recognizing non-sexual transmission would have another benefit: it would reduce stigma. If HIV positive Africans are told that it is almost certain that they were infected sexually, they will be stigmatized. Especially if it turns out that their partner is not infected. Allowing the possibility that HIV can be transmitted in other ways, which it most certainly can, could save a lot of marriages and lives, even the lives of children at risk of becoming infected.
There is some recognition that the state of public health facilities has direct consequences for the health of the people using those facilities. A lack of drugs, equipment and trained personnel has a negative impact on goals such as reducing child and maternal mortality, HIV transmission, malaria and other diseases.
Apparently, drugs and equipment can be stolen or may never reach health facilities. Sometimes patients have to bring the latex gloves and other equipment that will be used for their care. Perhaps sometimes equipment in short supply is reused, even without proper sterilization. But accepting that it can happen is not enough. It also needs to be established if this is contributing to transmission of diseases, such as HIV, and if so, how big this contribution is.
It's all very well to talk/write about destigmatization. But many of those doing the talking/writing are also doing the stigmatizing. There is plenty of evidence that HIV is not always transmitted sexually in Africa and there is evidence that possible cases of non-sexual transmission need to be investigated. Admitting this would go a long way towards reducing transmission, and also reducing stigmatization.
You will no more reduce stigmatization by saying 'stigma is bad' than you will influence sexual behavior by saying 'unprotected sex is risky'. We have learned that through many years of failing to have much impact on HIV transmission. The issue of stigma is very much in the hands of the people who warn us about how damaging it is, the UN, UNAIDS, WHO, CDC, the World Bank, etc.
The best way to reduce HIV transmission is to be clear about how the virus is being transmitted and not to depend on out of date and inappropriate figures. The best way to reduce mother to child transmission is to reduce the number of mothers being infected. And the best way to reduce stigma is to be honest about HIV transmission: we know that it is not always transmitted sexually and we don't even know how much is transmitted sexually.
Monday, June 13, 2011
Are UNAIDS Getting Off On Their Own Sexual Fantasies?
If paying for sex commoditizes it, does paying people not to have sex also commoditize it? Would anyone bribe their daughter with money to wait till they are married before they have sex? Or would they bribe them with money not to have sex for money? Somehow, I can't imagine parents thinking this way.
I don't know if paying girls not to have sex commoditizes it but I know it's one of the stories that does the rounds because it seems to appeal to journalists. And I know that UNAIDS sees it as worth a try in South Africa. I just can't see them trying it out in Washington DC (which might have the highest HIV rates in the Western world).
The article informs us that young South African girls are "one of the highest risk groups, because poverty drives them to have sex in exchange for gifts." What, all young girls? Or is it just all 'poor' young girls? "Researchers now want to see whether using cash payments as a reward for getting good grades and having annual HIV tests could curb the girls' risky sexual behaviour." So if the grades are not good and/or they don't have annual tests for some reason, no money for them?
Maybe things have changed radically in SA but only a few years ago "Startling new evidence from a three-year survey [showed] that HIV is now growing fastest among those who are wealthier and educated." This phenomenon is quite familiar in Kenya and even more so in Tanzania. In fact, the phenomenon is most marked among female Tanzanians: HIV rates are higher among well educated, well off Tanzanian women.
The Nature article is not too clear but I think it is saying that money is being given to boys and girls. Apparently boys are being involved because "Men are driving the epidemic — through their sexual behaviours, drug-taking, risk-taking and the fact that they often hold the balance of power in decision-making in intimate relationships."
Maybe the epidemic is being driven by men, but people could be forgiven for not being entirely convinced of that. HIV prevalence among females at age 15-19 is 6.7% and among males it is only 2.5%. We are informed, frequently, that young women sleep with older men. But how much older? And do all young women sleep with older men? Because in the 20-24 age group, female prevalence is 21.1% and male only 5.1.
Some estimates suggest that some (but by no means all) females sleep with men who are between five and ten years older than them. So if 15-19 year old females were sleeping with 20-24 year old men, it looks like a lot of the males are actually being infected by females, not the other way around. 6.7% of 15-19 year old females are infected, compared to 5.1% of 20-24 year old males. Sorry for being repetitive but these figures don't suggest that HIV transmission is being 'driven by men'.
Even if some young women have sex with much older men, there is no evidence that they all do. And while female prevalence peaks at 32.7% in the 25-29 year age group, it peaks at only 25.8% among 30-34 year old males, never reaching female prevalence rates in any age group. The figures could even suggest that the number of promiscuous females, if you go for the promiscuity theory of HIV transmission, radically outnumbers that of promiscuous males.
This doesn't really give credence to the idea that the epidemic is being driven by men. In fact, it might make you question the assumption that the epidemic is entirely driven by sex. You have huge numbers of females being infected at a very young age and far smaller numbers of men who could be infecting them. The whole principle behind making money from sex is that there are relatively few women being paid by a relatively large number of men.
If the number of women selling sex outnumbers the men buying it, the bottom falls out of the market. But, interestingly, if fewer women are willing to sell sex, the value will go up. If lots of these young females, said to be selling sex because they are so impoverished, suddenly disappear off the market, those left selling sex will be able to command a far higher price. The scheme may have some benefit, but probably not the one intended by UNAIDS!
But the two main claims in the article about paying young women not to have sex are that HIV is driven by large numbers of poor young women having sex for money and that HIV transmission is driven by (smaller numbers of) promiscuous men. Neither of these claims seems very plausible. What is plausible is that small numbers of poor young women have sex for money and that small numbers of promiscuous men pay for sex.
And this still doesn't explain extraordinarily high HIV prevalence figures found in South Africa, therefore it can not justify paying young girls (or boys) to not have sex. HIV prevention interventions need to be based on reality, rather than on the fantasies of a bunch of bureaucrats desperate to have something to show for the billions that have been poured into their institution.
Enabling girls to stay in school has been shown to reduce 'unsafe' sex, unplanned pregnancies and possibly sexually transmitted infections and HIV. But if HIV prevalence is usually higher among better educated girls, perhaps this needs to be investigated before spending money and precious time with interventions that may not work and that may make things worse. There is no substitute for establishing exactly how HIV is being transmitted in high prevalence contexts. Because we clearly don't know that yet.
I don't know if paying girls not to have sex commoditizes it but I know it's one of the stories that does the rounds because it seems to appeal to journalists. And I know that UNAIDS sees it as worth a try in South Africa. I just can't see them trying it out in Washington DC (which might have the highest HIV rates in the Western world).
The article informs us that young South African girls are "one of the highest risk groups, because poverty drives them to have sex in exchange for gifts." What, all young girls? Or is it just all 'poor' young girls? "Researchers now want to see whether using cash payments as a reward for getting good grades and having annual HIV tests could curb the girls' risky sexual behaviour." So if the grades are not good and/or they don't have annual tests for some reason, no money for them?
Maybe things have changed radically in SA but only a few years ago "Startling new evidence from a three-year survey [showed] that HIV is now growing fastest among those who are wealthier and educated." This phenomenon is quite familiar in Kenya and even more so in Tanzania. In fact, the phenomenon is most marked among female Tanzanians: HIV rates are higher among well educated, well off Tanzanian women.
The Nature article is not too clear but I think it is saying that money is being given to boys and girls. Apparently boys are being involved because "Men are driving the epidemic — through their sexual behaviours, drug-taking, risk-taking and the fact that they often hold the balance of power in decision-making in intimate relationships."
Maybe the epidemic is being driven by men, but people could be forgiven for not being entirely convinced of that. HIV prevalence among females at age 15-19 is 6.7% and among males it is only 2.5%. We are informed, frequently, that young women sleep with older men. But how much older? And do all young women sleep with older men? Because in the 20-24 age group, female prevalence is 21.1% and male only 5.1.
Some estimates suggest that some (but by no means all) females sleep with men who are between five and ten years older than them. So if 15-19 year old females were sleeping with 20-24 year old men, it looks like a lot of the males are actually being infected by females, not the other way around. 6.7% of 15-19 year old females are infected, compared to 5.1% of 20-24 year old males. Sorry for being repetitive but these figures don't suggest that HIV transmission is being 'driven by men'.
Even if some young women have sex with much older men, there is no evidence that they all do. And while female prevalence peaks at 32.7% in the 25-29 year age group, it peaks at only 25.8% among 30-34 year old males, never reaching female prevalence rates in any age group. The figures could even suggest that the number of promiscuous females, if you go for the promiscuity theory of HIV transmission, radically outnumbers that of promiscuous males.
This doesn't really give credence to the idea that the epidemic is being driven by men. In fact, it might make you question the assumption that the epidemic is entirely driven by sex. You have huge numbers of females being infected at a very young age and far smaller numbers of men who could be infecting them. The whole principle behind making money from sex is that there are relatively few women being paid by a relatively large number of men.
If the number of women selling sex outnumbers the men buying it, the bottom falls out of the market. But, interestingly, if fewer women are willing to sell sex, the value will go up. If lots of these young females, said to be selling sex because they are so impoverished, suddenly disappear off the market, those left selling sex will be able to command a far higher price. The scheme may have some benefit, but probably not the one intended by UNAIDS!
But the two main claims in the article about paying young women not to have sex are that HIV is driven by large numbers of poor young women having sex for money and that HIV transmission is driven by (smaller numbers of) promiscuous men. Neither of these claims seems very plausible. What is plausible is that small numbers of poor young women have sex for money and that small numbers of promiscuous men pay for sex.
And this still doesn't explain extraordinarily high HIV prevalence figures found in South Africa, therefore it can not justify paying young girls (or boys) to not have sex. HIV prevention interventions need to be based on reality, rather than on the fantasies of a bunch of bureaucrats desperate to have something to show for the billions that have been poured into their institution.
Enabling girls to stay in school has been shown to reduce 'unsafe' sex, unplanned pregnancies and possibly sexually transmitted infections and HIV. But if HIV prevalence is usually higher among better educated girls, perhaps this needs to be investigated before spending money and precious time with interventions that may not work and that may make things worse. There is no substitute for establishing exactly how HIV is being transmitted in high prevalence contexts. Because we clearly don't know that yet.
Thursday, June 9, 2011
HIV Treatment Has Come a Long Way, Prevention Has a Long Way to Go
South Africa, apparently, has a plan to "eliminate HIV in the next 30 years". The plan is based on a mathematical model, which assumes very high HIV prevalence and a population that will be tested once a year. Those found positive will be given antiretroviral drugs immediately, to take for the rest of their lives. The model says that this will eliminate the epidemic.
It would be interesting to know what figures they used in their model. South Africa has indeed tested many millions of people in the last twelve months, perhaps 12 million or more. But it has been estimated that people might need to be tested more frequently than once a year, perhaps twice or even four times a year. Will once a year be feasible, even if it turns out to be enough?
Sure, plenty of research has shown that a lot of people responding to antiretroviral treatment have a very low viral load and are unlikely to transmit the virus to their sexual partners. But that doesn't mean that 'test and treat', as it's called, will eradicate transmission altogether.
Recent research which gave rise to a lot of the hype about test and treat involved discordant couples. These are couples where only one person, the 'index case', is infected. It is believed that the index case will, sooner or later, infect their partner if they continue to have unprotected sex. The rate of transmission in discordant relationships is, indeed, very high. Putting the infected partners on drugs, assuming that they are found to be HIV positive early enough, could significantly reduce the risk to the HIV negative partner.
But that doesn't answer the question of how the index partner was infected. They would probably not have been protected by a test and treat policy, unless that policy was able to ensure that a huge percentage of new infections were discovered and treated very early on. But, while you can see the motivation for putting the HIV positive partner on drugs to protect the negative partner in discordant couples, in a couple where neither is positive there is no such motivation.
The South African plan doesn't deal with the issue of whether all HIV positive people will agree to or adhere to treatment. It doesn't even ask if putting people on treatment immediately is the best thing for those people's health. Leaving treatment till too late is clearly bad for people's health. But treating them too early, as well as being expensive and more likely to result in non-adherence and consequent resistance, may not be ethical.
It certainly won't be ethical if people are compelled to take the drugs, regardless of whether they need them or not. But there's also the question of whether people should take drugs for the benefit of others, or for the benefit of public health. [There's an interesting discussion of patient autonomy by Dr Joseph Sonnabend on his POZ blog.]
Treating more people, if and when they need treatment, is a good thing. Testing more people and testing them regularly is also good, especially if the results of such widespread testing are used to figure out why so many people become infected in South Africa. But test and treat alone is very unlikely to eliminate any epidemic in any country in 30 years, or even in 100 years.
No matter what any model (or 'expert') tells you, treating as many HIV positive people as possible is not the same as developing strategies to ensure that people don't become infected in the first place. Public health is a lot more complicated than any mathetical model can show. That's why so few diseases have ever been eradicated.
Diseases that have been virtually eradicated in some countries were not eradicated merely because of some powerful technology, either. They were eradicated because the conditions under which the disease is transmitted were also addressed. Water, sanitation and hygiene in the case of many diseases, air quality and habitation in the case of others, food and nutrition, living conditions, working conditions, etc. Test and treat remains relatively blind to the conditions under which HIV is transmitted (as has the HIV industry).
Alarmingly, research has shown that test and treat alone will not even come close to eradicating HIV in the US, where transmission is many times lower than in South Africa and the amount per head spent on healthcare is the highest in the world. And this is not because the universal testing part of the strategy is not in operation but because only 1 in 5 people on treatment have the undetectable viral load requried to ensure that they don't infect their partner through unprotected sex.
Test and treat is neither a miracle nor something that is impossible to effect. But it will not eradicate HIV epidemics, ever, anywhere. And public health experts should know that there is no such precedent for eradicating a disease that is transmitted in a number of ways (some of which are adequately acknowledged and some of which are not). It is wholly irresponsible to make the implicit promises that one hears constantly about test and treat.
There is a lot we don't yet know about HIV transmission and, apparently, a lot we are not very anxious to discuss. So let's not get distracted from HIV prevention by what is just one in a long line of hyped technical fixes. Test and treat, treatment as prevention, whatever you want to call it, will only ever be part of an effective strategy to eradicate HIV.
Wednesday, June 8, 2011
One Unsupported Assumption Can Infect a Whole Body of Research
The author of a book on AIDS with one of the most stigmatizing titles possible, Elizabeth Pisani, is interviewed by IRIN about why HIV prevention efforts have failed to curb the spread of the pandemic. One of the answers she gives is that we started too late, which I guess suggests that she thinks we have started now.
She's right about missing an important opportunity by not implementing needle exchange programs in some countries where the bulk of HIV transmission continues to occur among injecting drug users. Russia and a lot of Central and Eastern Europe are still dithering about such programs and the US continues to deprecate them, though they have worked well in countries where they have been implemented.
She's a bit wide of the mark in claiming that not targeting sex workers to reduce sexually transmitted infections represents a missed opportunity, certainly in the case of developing countries, anyhow. Trials on the impact of such interventions showed that they had little effect in reducing HIV transmission and some of them may have even increased the risks of non-sexual transmission for participants.
Pisani is right about abstinence not working very well but she failed to influence attitudes towards that 'strategy' when she was working at UNAIDS. But now that she's a rebel, working at the London School of Hygiene and Tropical Medicine, that bastion of public health reaction, going along with the HIV industry line that almost all HIV transmission in African countries results from heterosexual sex is unlikely to change things much.
Again, Pisani is right that the 'all men are evil, all women are innocent' reflex is not helpful and never has been. But she fails to mention the extent to which women are affected by HIV in comparison to men. Overall in Africa, in excess of 60% of HIV positive people are women and among young people, the figure is in excess of 70%. HIV prevention activity has failed to address that and the industry seems oblivious to it.
Pisani still holds her stigmatizing view of HIV transmission as being a matter of promiscuity, which it is not, and never has been. Data about sexual behavior, such as it is, shows that those who are infected with HIV often faced lower sexual risk than many who were not infected and some who took precautions were even more likely to be infected than some who did not. The idea that HIV is mainly about sex is unsupported by evidence, but still the mainstream view.
Treatment as prevention, we are told, is not the answer to ending HIV transmission. But anyone who thinks the strategy will address the needs of any more than a small subset of people has been brainwashed, anyway. But this is not an argument against expanding the number of people receiving treatment. So far, so good.
The author of the Wisdom of Whores, surprisingly, admits that she doesn't know what is the best approach to HIV prevention in sub-Saharan Africa. And she seems to have some intuition that incidence, the yearly rate of new infections, might rise. Unfortunately, we are not told what is behind this intuition so it's hard to say if it's one of her good ones or one of her not so good ones.
Ultimately, Pisani doesn't touch on the great elephant in the UNAIDS room: why a virus that is difficult to transmit heterosexually is said to be almost always transmitted heterosexually, but only in Africa, where sexual behavior is little different from that in many other places. She has never justified the highly stigmatizing title of her book, nor the attitude towards Africans which has had, and continues to have, so much influence on HIV policy.
Indeed, Pisani is one of the people behind the kind of dubious research and mathematical modelling that so much current HIV thinking is based on. The claim that HIV is mainly transmitted sexually in African countries, and hardly ever transmitted through non-sexual modes, is supported by the flimisiest evidence, at best. Until this massive flaw in mainstream HIV thinking is revised, prevention efforts will continue to have little impact on epidemics.
She's right about missing an important opportunity by not implementing needle exchange programs in some countries where the bulk of HIV transmission continues to occur among injecting drug users. Russia and a lot of Central and Eastern Europe are still dithering about such programs and the US continues to deprecate them, though they have worked well in countries where they have been implemented.
She's a bit wide of the mark in claiming that not targeting sex workers to reduce sexually transmitted infections represents a missed opportunity, certainly in the case of developing countries, anyhow. Trials on the impact of such interventions showed that they had little effect in reducing HIV transmission and some of them may have even increased the risks of non-sexual transmission for participants.
Pisani is right about abstinence not working very well but she failed to influence attitudes towards that 'strategy' when she was working at UNAIDS. But now that she's a rebel, working at the London School of Hygiene and Tropical Medicine, that bastion of public health reaction, going along with the HIV industry line that almost all HIV transmission in African countries results from heterosexual sex is unlikely to change things much.
Again, Pisani is right that the 'all men are evil, all women are innocent' reflex is not helpful and never has been. But she fails to mention the extent to which women are affected by HIV in comparison to men. Overall in Africa, in excess of 60% of HIV positive people are women and among young people, the figure is in excess of 70%. HIV prevention activity has failed to address that and the industry seems oblivious to it.
Pisani still holds her stigmatizing view of HIV transmission as being a matter of promiscuity, which it is not, and never has been. Data about sexual behavior, such as it is, shows that those who are infected with HIV often faced lower sexual risk than many who were not infected and some who took precautions were even more likely to be infected than some who did not. The idea that HIV is mainly about sex is unsupported by evidence, but still the mainstream view.
Treatment as prevention, we are told, is not the answer to ending HIV transmission. But anyone who thinks the strategy will address the needs of any more than a small subset of people has been brainwashed, anyway. But this is not an argument against expanding the number of people receiving treatment. So far, so good.
The author of the Wisdom of Whores, surprisingly, admits that she doesn't know what is the best approach to HIV prevention in sub-Saharan Africa. And she seems to have some intuition that incidence, the yearly rate of new infections, might rise. Unfortunately, we are not told what is behind this intuition so it's hard to say if it's one of her good ones or one of her not so good ones.
Ultimately, Pisani doesn't touch on the great elephant in the UNAIDS room: why a virus that is difficult to transmit heterosexually is said to be almost always transmitted heterosexually, but only in Africa, where sexual behavior is little different from that in many other places. She has never justified the highly stigmatizing title of her book, nor the attitude towards Africans which has had, and continues to have, so much influence on HIV policy.
Indeed, Pisani is one of the people behind the kind of dubious research and mathematical modelling that so much current HIV thinking is based on. The claim that HIV is mainly transmitted sexually in African countries, and hardly ever transmitted through non-sexual modes, is supported by the flimisiest evidence, at best. Until this massive flaw in mainstream HIV thinking is revised, prevention efforts will continue to have little impact on epidemics.
Sunday, June 5, 2011
The Myth about HIV and Sex: 30 Years in the Making
Today marks the 30th anniversary of the discovery of HIV. When the virus was discovered, it was still being transmitted rapidly in high prevalence countries, mostly in Africa. But over the ten years or so following its discovery, transmission declined, even in high prevalence countries. In Kenya, incidence peaked in the early to mid 1990s, almost a decade before the government even admitted that there was a HIV epidemic there.
Similar patterns are found in other countries. HIV incidence peaked before most people had even heard of the virus, many years before in most countries in Africa. So why did the virus decline? Because people who had spontaneously begun to have outrageous amounts of sex in the late 1970s and early 1980s, just as spontaneously ceased to have such outrageous amounts of sex in the late 1980s and early 1990s, and that trend continued up to the present?
That's what the HIV industry would have you believe, anyhow. For them, something like that story is true, although they don't ask why people would suddenly and profoundly change their sexual habits twice in the space of less than 20 years. And they don't allude to the fact that incidence, the yearly rate of new infections, peaked and declined long before mass HIV 'prevention' campaigns even started.
Thirty years ago, it was still permissble to talk about there being several ways for HIV to be transmitted, especially in a rich country context. After all, it was hardly ever transmitted through heterosexual sex in rich countries and it is even less so now. In rich countries, HIV was always transmitted mainly through men having sex with men and intravenous drug use. But talk of non-sexual transmission has declined significantly over the last 30 years.
In African countries, HIV was first noticed to reach massive levels in sex worker populations. In Kenya, prevalence is said to have reached over 80%, in Tanzania, over 70%. And this is in populations where hardly any men were infected. The fact that these ridiculous and completely unacceptable levels were found in sex workers who had been put through sexually transmitted infection (STI) programs has since been conveniently ignored. As I said, talk about such things has declined.
Fingers have been pointed, but in rich countries those fingers were pointed at men who have sex with men and intravenous drug users. Sex workers were also implicated but it's hard to see why because HIV rates were always low, except among sex workers who were also intravenous drug users.
But in African countries, fingers were pointed at men who have sex with men, commercial sex workers, truckers, soldiers, police, prisoners, internal migrants, migrant workers, internally displaced persons, fishing populations, those who engage in 'cultural practices' (such as wife inheritance, ritual cleansing, etc), teachers, 'sugar daddies', clients of commercial sex workers, partners of men who have sex with men, uncircumcised men, circumcised women, polygamists, bigamists, alcohol users, khat chewers, (non-injecting) drug users, sex tourists, Ugandans, young women and girls, older men who marry younger women, and the list goes on.
Most of these groups are still considered to be 'most at risk' populations or 'MARP'. And yet, modes of transmission surveys show that in African countries, the biggest groups of HIV positive people engage in low risk sex. Those surveys completely ignore the fact that many HIV positive people don't engage in sex at all, or hardly at all, those who take precautions are often more likely to be infected than those who do not and various other details which don't fit into the picture of the sexually animalistic African that UNAIDS has built up over the years.
UNAIDS often bandies about authoritative sounding figures, such as that 80% (sometimes even 90%) of HIV in some African countries is heterosexually transmitted. But it's interesting to see what these modes of transmission surveys are based on. There is an oft cited article that seems to have a disproportionate influence on HIV policy documents by Eleanor Gouws and others but this is based on a simplistic piece of mathematical modelling with some highly questionable figures.
If you don't believe that the mathematical model is simplistic and that the figures are questionable, you can download it and play around with it. You might be struck by the transmission probability per risky exposure act, for example. The risk for sex workers is dubious, but the risk for clients, at half the risk for sex workers, is even more so. And the risk for clients' partners is the same as that for sex workers, as is that of various other groups.
The risk for casual heterosexual sex, partners of those who engage in casual heterosexual sex and low-risk heterosexual sex is questionable enough as well. And only 10% of the population are deemed to have no risk from their sexual behavior. That's in African populations, of course! As I've said, heterosexual sex poses little or no risk to people outside of a few African countries, even in certain parts of some high prevalence African countries (such as Zanzibar and Kenya's North Eastern Province, where prevalence is lower than in a lot of US cities).
But the most laughable parts of the model relate to risks from unsafe medical injections and blood transfusions. Gouws estimated these risks to be very low, contributing less than 1% of all infections. UNAIDS ups that figure to a little over 2% when you add unsafe injections and unsafe blood transfusions together. However, this ignores any other kind of medical risk, such as from contaminated gloves, instruments and machinery of various kinds in sub-standard hospitals, wielded by poorly trained, underequipped personnel. (You can try plugging in some of the figures from here, or just make some up. UNAIDS did.)
Anyhow, the transmission probability per risky exposure act for these two items is absurd. You can try the model with a more reasonable value, even if it's just the figure for injecting drug use, and you get a far more credible estimate for the contribution of unsafe healthcare including, but not limited to, unsterile injections. And if you change the number of injections per year to something more reasonable you will also see the contribution of these non-sexual transmission modes rocketing up.
Looking at figures provided by the Kenyan Demographic and Health Survey (or the Tanzanian one, or that for many other African countries) you would be forgiven for thinking that females tend to become infected first and later infect their male partners. Far more females are infected than males, they are infected at earlier ages and rates exceed rates for males until many years of sexual activity have passed. In some population groups the number of females infected can exceed the number of males infected by 4 or 5 to one.
Does this mean that HIV is not almost always heterosexually transmitted? Certainly not. Nor does it mean that non-sexual transmission, such as through unsafe healthcare, is high, let alone higher than heterosexual transmission. It means that we don't have the faintest idea how high non-sexual HIV transmission is, relative to heterosexual transmission. And if you are puzzled at the fact that HIV prevalence is highest among young heterosexual women in a few African countries, and virtually nowhere else in the world, then you are awake (and almost certainly not working for UNAIDS or any of the HIV industry).
And yet, not only are men who have sex with men and intravenous drug users hardly ever targeted in high prevalence countries, but sex workers are not even targeted consistently in most. 'Prevention' spending represents less than 25% of HIV spending in countries like Kenya. How much less is unclear because about 80% of that is spent on unspecified prevention activities. In other words, no one has a clue what it's being spent on and they probably don't care Even youth are not a particularly lucky group, receiving only about 5% of prevention spending. And that shows. Over 70% of infected youth in African countries are females.
And who infects them? Well, if 80% (or 90%) of transmission is heterosexual, men, of course. But which men? UNAIDS and the HIV industry can't say. Give them another thirty years of highly distorting funding and they may modify their answer. Some patterns may be consistent with HIV being sexually transmitted, but this does not mean that it always is. And some patterns are consistent with HIV being transmitted in STI clinics and other medical facilities.
But read around the data on non-sexual HIV transmission, especially unsterile injections, and you'll find that there is "Very little information on injections safety" and that it is "hard to get baselines". In fact, there is "no data about the quality of service provision". This is also a good time to look at the latest Service Provision Assessment for Kenya, which won't tell you as much about quality as it does about quantity.
The Modes of Transmission conclusion about service provision is brief, but telling: "in the future, Kenya will have to spend more time and effort analysing and assessing the quality of services provided – providing a bad service (particularly in the sensitive areas of sexual behaviour) may be worse than not providing a service at all."
What could this mean? Could it mean that the many people who do not have access to any health facilities might thereby be avoiding infection with HIV, hepatitis and various other diseases? Could it mean that people who get large numbers of injections in STI clinics every year, for STIs, hormonal contraception, etc, might face a high risk of HIV and other infection there?
HIV prevalence figures in both Kenya and Tanzania tend to be lower in areas where people have little or no access to healthcare. Unprotected sex tends to be more common in those areas. It doesn't take a genius to work out that HIV is not all about sex, but also that it could have an awful lot to do with unsafe healthcare. If even UNAIDS could inadvertently come to that conclusion, anyone can. But now it's time for UNAIDS to do what they have avoided doing for so many years: empirical research into the relative contribution of non-sexual HIV transmission in high HIV prevalence countries.
Similar patterns are found in other countries. HIV incidence peaked before most people had even heard of the virus, many years before in most countries in Africa. So why did the virus decline? Because people who had spontaneously begun to have outrageous amounts of sex in the late 1970s and early 1980s, just as spontaneously ceased to have such outrageous amounts of sex in the late 1980s and early 1990s, and that trend continued up to the present?
That's what the HIV industry would have you believe, anyhow. For them, something like that story is true, although they don't ask why people would suddenly and profoundly change their sexual habits twice in the space of less than 20 years. And they don't allude to the fact that incidence, the yearly rate of new infections, peaked and declined long before mass HIV 'prevention' campaigns even started.
Thirty years ago, it was still permissble to talk about there being several ways for HIV to be transmitted, especially in a rich country context. After all, it was hardly ever transmitted through heterosexual sex in rich countries and it is even less so now. In rich countries, HIV was always transmitted mainly through men having sex with men and intravenous drug use. But talk of non-sexual transmission has declined significantly over the last 30 years.
In African countries, HIV was first noticed to reach massive levels in sex worker populations. In Kenya, prevalence is said to have reached over 80%, in Tanzania, over 70%. And this is in populations where hardly any men were infected. The fact that these ridiculous and completely unacceptable levels were found in sex workers who had been put through sexually transmitted infection (STI) programs has since been conveniently ignored. As I said, talk about such things has declined.
Fingers have been pointed, but in rich countries those fingers were pointed at men who have sex with men and intravenous drug users. Sex workers were also implicated but it's hard to see why because HIV rates were always low, except among sex workers who were also intravenous drug users.
But in African countries, fingers were pointed at men who have sex with men, commercial sex workers, truckers, soldiers, police, prisoners, internal migrants, migrant workers, internally displaced persons, fishing populations, those who engage in 'cultural practices' (such as wife inheritance, ritual cleansing, etc), teachers, 'sugar daddies', clients of commercial sex workers, partners of men who have sex with men, uncircumcised men, circumcised women, polygamists, bigamists, alcohol users, khat chewers, (non-injecting) drug users, sex tourists, Ugandans, young women and girls, older men who marry younger women, and the list goes on.
Most of these groups are still considered to be 'most at risk' populations or 'MARP'. And yet, modes of transmission surveys show that in African countries, the biggest groups of HIV positive people engage in low risk sex. Those surveys completely ignore the fact that many HIV positive people don't engage in sex at all, or hardly at all, those who take precautions are often more likely to be infected than those who do not and various other details which don't fit into the picture of the sexually animalistic African that UNAIDS has built up over the years.
UNAIDS often bandies about authoritative sounding figures, such as that 80% (sometimes even 90%) of HIV in some African countries is heterosexually transmitted. But it's interesting to see what these modes of transmission surveys are based on. There is an oft cited article that seems to have a disproportionate influence on HIV policy documents by Eleanor Gouws and others but this is based on a simplistic piece of mathematical modelling with some highly questionable figures.
If you don't believe that the mathematical model is simplistic and that the figures are questionable, you can download it and play around with it. You might be struck by the transmission probability per risky exposure act, for example. The risk for sex workers is dubious, but the risk for clients, at half the risk for sex workers, is even more so. And the risk for clients' partners is the same as that for sex workers, as is that of various other groups.
The risk for casual heterosexual sex, partners of those who engage in casual heterosexual sex and low-risk heterosexual sex is questionable enough as well. And only 10% of the population are deemed to have no risk from their sexual behavior. That's in African populations, of course! As I've said, heterosexual sex poses little or no risk to people outside of a few African countries, even in certain parts of some high prevalence African countries (such as Zanzibar and Kenya's North Eastern Province, where prevalence is lower than in a lot of US cities).
But the most laughable parts of the model relate to risks from unsafe medical injections and blood transfusions. Gouws estimated these risks to be very low, contributing less than 1% of all infections. UNAIDS ups that figure to a little over 2% when you add unsafe injections and unsafe blood transfusions together. However, this ignores any other kind of medical risk, such as from contaminated gloves, instruments and machinery of various kinds in sub-standard hospitals, wielded by poorly trained, underequipped personnel. (You can try plugging in some of the figures from here, or just make some up. UNAIDS did.)
Anyhow, the transmission probability per risky exposure act for these two items is absurd. You can try the model with a more reasonable value, even if it's just the figure for injecting drug use, and you get a far more credible estimate for the contribution of unsafe healthcare including, but not limited to, unsterile injections. And if you change the number of injections per year to something more reasonable you will also see the contribution of these non-sexual transmission modes rocketing up.
Looking at figures provided by the Kenyan Demographic and Health Survey (or the Tanzanian one, or that for many other African countries) you would be forgiven for thinking that females tend to become infected first and later infect their male partners. Far more females are infected than males, they are infected at earlier ages and rates exceed rates for males until many years of sexual activity have passed. In some population groups the number of females infected can exceed the number of males infected by 4 or 5 to one.
Does this mean that HIV is not almost always heterosexually transmitted? Certainly not. Nor does it mean that non-sexual transmission, such as through unsafe healthcare, is high, let alone higher than heterosexual transmission. It means that we don't have the faintest idea how high non-sexual HIV transmission is, relative to heterosexual transmission. And if you are puzzled at the fact that HIV prevalence is highest among young heterosexual women in a few African countries, and virtually nowhere else in the world, then you are awake (and almost certainly not working for UNAIDS or any of the HIV industry).
And yet, not only are men who have sex with men and intravenous drug users hardly ever targeted in high prevalence countries, but sex workers are not even targeted consistently in most. 'Prevention' spending represents less than 25% of HIV spending in countries like Kenya. How much less is unclear because about 80% of that is spent on unspecified prevention activities. In other words, no one has a clue what it's being spent on and they probably don't care Even youth are not a particularly lucky group, receiving only about 5% of prevention spending. And that shows. Over 70% of infected youth in African countries are females.
And who infects them? Well, if 80% (or 90%) of transmission is heterosexual, men, of course. But which men? UNAIDS and the HIV industry can't say. Give them another thirty years of highly distorting funding and they may modify their answer. Some patterns may be consistent with HIV being sexually transmitted, but this does not mean that it always is. And some patterns are consistent with HIV being transmitted in STI clinics and other medical facilities.
But read around the data on non-sexual HIV transmission, especially unsterile injections, and you'll find that there is "Very little information on injections safety" and that it is "hard to get baselines". In fact, there is "no data about the quality of service provision". This is also a good time to look at the latest Service Provision Assessment for Kenya, which won't tell you as much about quality as it does about quantity.
The Modes of Transmission conclusion about service provision is brief, but telling: "in the future, Kenya will have to spend more time and effort analysing and assessing the quality of services provided – providing a bad service (particularly in the sensitive areas of sexual behaviour) may be worse than not providing a service at all."
What could this mean? Could it mean that the many people who do not have access to any health facilities might thereby be avoiding infection with HIV, hepatitis and various other diseases? Could it mean that people who get large numbers of injections in STI clinics every year, for STIs, hormonal contraception, etc, might face a high risk of HIV and other infection there?
HIV prevalence figures in both Kenya and Tanzania tend to be lower in areas where people have little or no access to healthcare. Unprotected sex tends to be more common in those areas. It doesn't take a genius to work out that HIV is not all about sex, but also that it could have an awful lot to do with unsafe healthcare. If even UNAIDS could inadvertently come to that conclusion, anyone can. But now it's time for UNAIDS to do what they have avoided doing for so many years: empirical research into the relative contribution of non-sexual HIV transmission in high HIV prevalence countries.
Sunday, May 29, 2011
Killing Kenyans, Saving UN Employees: it's a matter of priorities
I'm still trying to reconcile two claims from UNAIDS: the first is that 80% of HIV transmission is a result of heterosexual sex in African countries (in most non-African countries it's mainly a result of male to male anal sex and intravenous drug use). An estimated 18% of transmission in African countries is from mother to child. And only the remaining 2% is a result of unsafe health care.
The second claim is that "We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere."
Evidently, non-UN approved hospitals do not take all the necessary precautions to prevent accidental exposure to contaminated blood, nor can they be guaranteed to use new or sterilized equipment. The 2% figure estimated (and it is an estimate, no empirical data has ever been made available to support it) is so low, it can be assumed that only the kind of small clinics found in outlying areas would be responsible for much of it.
So why the need to warn UN employees? There is certainly no danger to them. Or, turning things around, why is there no need to warn Kenyans and other Africans? Most poor Kenyans will rarely see a doctor and much of the treatment they receive will be rushed, performed by badly trained, badly supervised, underequipped personnel, perhaps even people who know nothing about infection control.
Because many people working in health know little about infection control. Many health facilities have few infection control supplies, people who know how to use them or studies to find out if the little available is ever utilized. UN employees are probably in little danger when it comes to health care. But Kenyans face many dangers.
The latest Service Provision Assessment for Kenya (2010) is now available from the MeasureDHS website. This assesses the availability and quality of services from a representative sample of over 700 health facilities, ranging from regional hospitals to voluntary counselling and testing (VCT)acentres to dispensaries and small, rural clinics.
When it comes to infection control, the survey makes especially sorry reading. Only 80% of standalone VCT clinics have both soap and water. The figures for all other types of health facility are even lower, with only 30% or fewer hospitals, health centres and maternity facilities having such basic items.
While 93% of VCT clinics manage to have clean latex or sterile gloves, only two thirds of hospitals and health centres do, and less than 80% of materity facilities do. In fact, only 12% of hospitals have all the basic items needed for infection control. Again, the highest figure is from VCT clinics, where 66% 'make the grade'.
When it comes to supplies of items needed, fewer than 30% of facilities in all categories have all the items and none of the VCT clinics have all of them. It may not be so bad for only 14% of VCT clinics to have supplies of needles and syringes. But only 89% of hospitals, 86% of health centres and 93% of maternity facilities have them.
As for the disposal of contaminated waste, especially sharps, such as needles and scalpels, the majority of facilities don't even have the basics. Sterilization equipment is lacking in many and, even where it exists, there are often no people or equipment to ensure its use. Written guidelines or procedures are also missing in the majority of facilities.
As the Service Provision Assessment itself makes clear, the presence of trained personnel, equipment, guidelines or anything else gives no indication of whether infection control actually takes place, how often and to what extent. If there are any serious breeches, they are unlikely even to be logged, let alone investigated or addressed.
So it seems that UN employees probably do need to be warned. But if so, ordinary Kenyans and other Africans are in far greater danger than pampered foreigners who travel in air conditioned vehicles and have access to some of the best facilities and expertise in the world, and that's not just in health care, either.
Kenyans and other Africans need to be aware that the state of their health facilities is such that their safety from blood borne and other infections is most definitely not assured. Kenyan hospitals are shabby, understaffed and underequipped. It is not clear how much HIV (or other diseases) have been spread by health care procedures because the matter has never been investigated. But it is time to investigate now.
The second claim is that "We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere."
Evidently, non-UN approved hospitals do not take all the necessary precautions to prevent accidental exposure to contaminated blood, nor can they be guaranteed to use new or sterilized equipment. The 2% figure estimated (and it is an estimate, no empirical data has ever been made available to support it) is so low, it can be assumed that only the kind of small clinics found in outlying areas would be responsible for much of it.
So why the need to warn UN employees? There is certainly no danger to them. Or, turning things around, why is there no need to warn Kenyans and other Africans? Most poor Kenyans will rarely see a doctor and much of the treatment they receive will be rushed, performed by badly trained, badly supervised, underequipped personnel, perhaps even people who know nothing about infection control.
Because many people working in health know little about infection control. Many health facilities have few infection control supplies, people who know how to use them or studies to find out if the little available is ever utilized. UN employees are probably in little danger when it comes to health care. But Kenyans face many dangers.
The latest Service Provision Assessment for Kenya (2010) is now available from the MeasureDHS website. This assesses the availability and quality of services from a representative sample of over 700 health facilities, ranging from regional hospitals to voluntary counselling and testing (VCT)acentres to dispensaries and small, rural clinics.
When it comes to infection control, the survey makes especially sorry reading. Only 80% of standalone VCT clinics have both soap and water. The figures for all other types of health facility are even lower, with only 30% or fewer hospitals, health centres and maternity facilities having such basic items.
While 93% of VCT clinics manage to have clean latex or sterile gloves, only two thirds of hospitals and health centres do, and less than 80% of materity facilities do. In fact, only 12% of hospitals have all the basic items needed for infection control. Again, the highest figure is from VCT clinics, where 66% 'make the grade'.
When it comes to supplies of items needed, fewer than 30% of facilities in all categories have all the items and none of the VCT clinics have all of them. It may not be so bad for only 14% of VCT clinics to have supplies of needles and syringes. But only 89% of hospitals, 86% of health centres and 93% of maternity facilities have them.
As for the disposal of contaminated waste, especially sharps, such as needles and scalpels, the majority of facilities don't even have the basics. Sterilization equipment is lacking in many and, even where it exists, there are often no people or equipment to ensure its use. Written guidelines or procedures are also missing in the majority of facilities.
As the Service Provision Assessment itself makes clear, the presence of trained personnel, equipment, guidelines or anything else gives no indication of whether infection control actually takes place, how often and to what extent. If there are any serious breeches, they are unlikely even to be logged, let alone investigated or addressed.
So it seems that UN employees probably do need to be warned. But if so, ordinary Kenyans and other Africans are in far greater danger than pampered foreigners who travel in air conditioned vehicles and have access to some of the best facilities and expertise in the world, and that's not just in health care, either.
Kenyans and other Africans need to be aware that the state of their health facilities is such that their safety from blood borne and other infections is most definitely not assured. Kenyan hospitals are shabby, understaffed and underequipped. It is not clear how much HIV (or other diseases) have been spread by health care procedures because the matter has never been investigated. But it is time to investigate now.
Wednesday, May 18, 2011
Low Figures for Hospital Acquired Infections Due to Lack of Research
The UN development news agency IRIN has an article entitled 'For want of a mask', about TB in health workers. Masks are cheap, but vital, to comply with all sorts of procedures. So why would health workers lack something so basic, something that can protect both health workers and patients?
The Service Provision Assessment for Kenya, produced by Demographic and Health Surveys, shows that masks are not all Kenyan health facilities lack. Running water is available in about half of all facilities, soap in 70%, latex gloves in 87%, sharps disposal box in 73% and chlorine solution in only 28% of facilities.
That's 15% who have all items for relevant service areas. When it comes to stocks of infection control items,things little better. While 89% have high level sterilization equipment, bleach and injecting equipment, only half have latex gloves and only 40% have all items in stock. So only 3% of Kenyan facilities have everything they need.
So it's not just TB infection that people need worry about, there are also blood borne infections, such as HIV, hepatitis and bacterial infections, amongst others. But TB is exceptionally high in Kenya considering it is so commonly associated with HIV. Because, while Kenya is fifth highest in Africa for TB burden, HIV prevalence there is a lot lower than in the five highest HIV prevalence countries.
The article on TB makes it clear that even where safety supplies are lacking, health services still have to be supplied. Health personnel and patients face considerable risks of being infected through the health facility and health related procedures, testing, treatment or preventative, rather than through normal person to person contact.
Apparently supply chains, funding, management, theft and corruption have all been blamed for shortages. Drugs also, are said to be in short supply, for similar reasons. Equipment, drugs and other items can even be sold off to private pharmacies.
In addition to shortages of supplies, there is also the problem of use. Even when masks are available they are not always used. Some supplies may be misused, with gloves and perhaps other items being reused. That certainly happens in wealthy countries, where such matters are routinely investigated, so it would be unsurprising if it didn't happen in destitute countries.
An article on safe injection practices finds that there have been 30 infectious disease outbreaks in the last ten years in the US and they call for education, research and better products to ensure safe injection. More than 125,000 patients have been notified about potential exposure due to reuse of syringes.
Even if injection equipment reuse in Africa was only as high as that in the US, that would mean about 400,000 people could have been exposed. But the number notified, apparently, is zero. Not only do Africans not get recalled under such circumstances, but injection reuse hardly ever occurs in African countries, according to UNAIDS and others. And that is despite the figures from the Kenyan Service Provision Assessment, cited above.
Given conditions in Kenyan health facilities, I think it is fair to say that there is far more scope for hospital transmitted infection there than in the worst US hospital. I can't cite any research to back up that claim because virtually no research has been done on infection control in African countries. And that's what makes me question the figure UNAIDS gives for the contribution of unsafe health care to Kenya's HIV epidemic, 2%. Where is their research?
The Service Provision Assessment for Kenya, produced by Demographic and Health Surveys, shows that masks are not all Kenyan health facilities lack. Running water is available in about half of all facilities, soap in 70%, latex gloves in 87%, sharps disposal box in 73% and chlorine solution in only 28% of facilities.
That's 15% who have all items for relevant service areas. When it comes to stocks of infection control items,things little better. While 89% have high level sterilization equipment, bleach and injecting equipment, only half have latex gloves and only 40% have all items in stock. So only 3% of Kenyan facilities have everything they need.
So it's not just TB infection that people need worry about, there are also blood borne infections, such as HIV, hepatitis and bacterial infections, amongst others. But TB is exceptionally high in Kenya considering it is so commonly associated with HIV. Because, while Kenya is fifth highest in Africa for TB burden, HIV prevalence there is a lot lower than in the five highest HIV prevalence countries.
The article on TB makes it clear that even where safety supplies are lacking, health services still have to be supplied. Health personnel and patients face considerable risks of being infected through the health facility and health related procedures, testing, treatment or preventative, rather than through normal person to person contact.
Apparently supply chains, funding, management, theft and corruption have all been blamed for shortages. Drugs also, are said to be in short supply, for similar reasons. Equipment, drugs and other items can even be sold off to private pharmacies.
In addition to shortages of supplies, there is also the problem of use. Even when masks are available they are not always used. Some supplies may be misused, with gloves and perhaps other items being reused. That certainly happens in wealthy countries, where such matters are routinely investigated, so it would be unsurprising if it didn't happen in destitute countries.
An article on safe injection practices finds that there have been 30 infectious disease outbreaks in the last ten years in the US and they call for education, research and better products to ensure safe injection. More than 125,000 patients have been notified about potential exposure due to reuse of syringes.
Even if injection equipment reuse in Africa was only as high as that in the US, that would mean about 400,000 people could have been exposed. But the number notified, apparently, is zero. Not only do Africans not get recalled under such circumstances, but injection reuse hardly ever occurs in African countries, according to UNAIDS and others. And that is despite the figures from the Kenyan Service Provision Assessment, cited above.
Given conditions in Kenyan health facilities, I think it is fair to say that there is far more scope for hospital transmitted infection there than in the worst US hospital. I can't cite any research to back up that claim because virtually no research has been done on infection control in African countries. And that's what makes me question the figure UNAIDS gives for the contribution of unsafe health care to Kenya's HIV epidemic, 2%. Where is their research?
Monday, May 16, 2011
Biological Factors that May Contribute to Huge Disparities in HIV Prevalence
The brief summary at the end of an excellent article on 'Biological Factors that May Contribute to Regional and Racial Disparities in HIV Prevalence' really gets to the point about how HIV prevention should be approached, but generally isn't:
"To develop better prevention tools, it is critical that communities, researchers and policy makers come together to discuss and investigate these tremendous [racial disparities in HIV prevalence, both between regions and within regions] in an open and non-judgmental fashion."
Instead, it is generally assumed that HIV transmission is driven by "stigmatizing socio-behavioural factors such as sexual concurrency or promiscuity, partner violence and so on." This article emphasizes that "biological factors such as endemic co-infections and immunology also play a key role."
The authors warn against blaming affected communities and individuals, something the HIV mainstream have been guilty of while at the same time, rather perversely, warning those in high prevalence communities that they should avoid stigmatizing attitudes. The highest prevalence figures are found in a handful of African countries and in specific regions in some countries.
Occasional mention is made about how inefficient heterosexual sex is when it comes to transmitting HIV, but without any logical conclusions being drwan from that fact. While the probability of transmission resulting from penile-vaginal sex appears to be higher in African countries, such transmission is still "the rare exception rather than the rule."
Co-infections with diseases common in African countries, such as TB, malaria (see also this abstract on malaria as a co-factor in HIV transmission) and various kinds of parasitic conditions may increase transmission by those infected with HIV and increase susceptibility in those uninfected. While it has been recognised that could treating these conditions would reduce transmission, no clinical trials have assessed the impact this might have.
Similar remarks apply to various sexually transmitted infections (STI). But while some trials have looked at reducing STIs as a means of reducing HIV transmission, factors such as non-sexual HIV transmission, perhaps through the STI treatment itself, may not have been taken into account. So not enough is yet known about this kind of intervention.
Male circumcision is discussed and the authors mention that HIV prevalence is higher in a non-circumcising population in Kenya's Nyanza's province. However, they don't mention that there are non-circumcising populations in other countries where HIV prevalence is lower than in circumcising populations.
Also, low HIV prevalence is often correlated with female genital mutilation (FGM), even in Nyanza province itself. The Luo tribe may not circumcise their men, but they don't circumcise their women either. Whereas in tribes that circumcise men and women, such as the Kisii, HIV prevalence is lower than national prevalence. Other tribes that practice FGM, such as the Somali, have even lower HIV prevalence than the Kisii.
Personally, I am opposed to FGM, but the arguments for male circumcision seem equally unconvincing. Some even claim that male circumcision reduces the number of Langerhans cells, which HIV targets. But there are Langerhans cells in the vagina as well and no one would argue that parts of it should be surgically removed to reduce susceptibility to HIV infection.
But if you are opposed to the view that Africans have extraordinary and probably animalistic sex lives, that they care little for their own health and welfare, or for that of their partners and their children, you need to read the above article.
"To develop better prevention tools, it is critical that communities, researchers and policy makers come together to discuss and investigate these tremendous [racial disparities in HIV prevalence, both between regions and within regions] in an open and non-judgmental fashion."
Instead, it is generally assumed that HIV transmission is driven by "stigmatizing socio-behavioural factors such as sexual concurrency or promiscuity, partner violence and so on." This article emphasizes that "biological factors such as endemic co-infections and immunology also play a key role."
The authors warn against blaming affected communities and individuals, something the HIV mainstream have been guilty of while at the same time, rather perversely, warning those in high prevalence communities that they should avoid stigmatizing attitudes. The highest prevalence figures are found in a handful of African countries and in specific regions in some countries.
Occasional mention is made about how inefficient heterosexual sex is when it comes to transmitting HIV, but without any logical conclusions being drwan from that fact. While the probability of transmission resulting from penile-vaginal sex appears to be higher in African countries, such transmission is still "the rare exception rather than the rule."
Co-infections with diseases common in African countries, such as TB, malaria (see also this abstract on malaria as a co-factor in HIV transmission) and various kinds of parasitic conditions may increase transmission by those infected with HIV and increase susceptibility in those uninfected. While it has been recognised that could treating these conditions would reduce transmission, no clinical trials have assessed the impact this might have.
Similar remarks apply to various sexually transmitted infections (STI). But while some trials have looked at reducing STIs as a means of reducing HIV transmission, factors such as non-sexual HIV transmission, perhaps through the STI treatment itself, may not have been taken into account. So not enough is yet known about this kind of intervention.
Male circumcision is discussed and the authors mention that HIV prevalence is higher in a non-circumcising population in Kenya's Nyanza's province. However, they don't mention that there are non-circumcising populations in other countries where HIV prevalence is lower than in circumcising populations.
Also, low HIV prevalence is often correlated with female genital mutilation (FGM), even in Nyanza province itself. The Luo tribe may not circumcise their men, but they don't circumcise their women either. Whereas in tribes that circumcise men and women, such as the Kisii, HIV prevalence is lower than national prevalence. Other tribes that practice FGM, such as the Somali, have even lower HIV prevalence than the Kisii.
Personally, I am opposed to FGM, but the arguments for male circumcision seem equally unconvincing. Some even claim that male circumcision reduces the number of Langerhans cells, which HIV targets. But there are Langerhans cells in the vagina as well and no one would argue that parts of it should be surgically removed to reduce susceptibility to HIV infection.
But if you are opposed to the view that Africans have extraordinary and probably animalistic sex lives, that they care little for their own health and welfare, or for that of their partners and their children, you need to read the above article.
Wednesday, March 31, 2010
Human Rights Are Not Just for the Rich World
According to Dr Marcos Espinal of the Stop TB Partnership, "TB is not a medical problem. It is a development issue. It is an economic problem. It's a human rights situation." And I applaud him for saying this. If developing countries are not allowed to develop (and I would argue that developed countries are doing all in their power to stop them from developing), diseases like TB will not successfully be treated by drugs alone. People in developing countries are poor, they suffer bad health, they receive little or no education, they live in terrible conditions and their human rights are being denied. It is no wonder that TB and many other diseases are rife and increasing.
I would add that HIV, also, is not just a medical problem, nor is it just a matter of sexual behaviour. Parallel arguments could be used to show that, so far, both HIV and TB programmes have failed to prevent the spread of the diseases and will continue to do so. If you don't deal with the conditions that result in diseases spreading, all diseases, you will not eradicate the diseases. After using little more than expensive pharmaceutical products to treat TB for many years, an estimated 440,000 people are now resistant to commonly used TB drugs. I have not been able to find estimates for the number of people with HIV strains that are resistant to first line drugs commonly used in developing countries, but resistance is a very serious threat.
There's an interesting article on the website of the United Nations Development Programme (UNDP). They have been publishing the Human Development Report for many years now and they are about to reveal some of the main trends over the past four decades. The Human Development Report measures development by criteria other than just economic, such as health, gender, education and other things. This article notes that there has been significant progress in development, but this has come from improvements in education and health, not economics.
It also notes that these improvements have little or nothing to do with globalization. Rather, they have been achieved by expansion of "educational and health systems, coupled by initiatives of the international community to enable access to vaccines and antibiotics." In other words, state intervention.
The research finds that there is no correlation between economic growth and changes in non-income components of human development. It concludes that "the oft-repeated dictum that growth is a necessary condition for increasing human development is simply not true."
So the approach to development and human rights related problem, such as HIV or TB, is to improve education, health, economic circumstances, gender imbalances, employment, infrastructure and many other things. The approach should not be to set up well financed vertical programmes that target single diseases or narrow issues at the expense of other, broader issues.
Throwing eye watering sums of money at a problem, such as HIV or TB, will not even solve the problems of HIV or TB. Especially if most of the money is spent on technologies that are produced in rich countries. That's just taking money out of one pocket and slipping most of it into another. It's time for new thinking on development. Development is not just one thing, it's many things. And if you don't know enough about any of them, just read the Universal Declaration of Human Rights and consider how many of those rights people in developing countries are currently being denied.
Tuesday, March 30, 2010
More Good News for Big Pharma: Resistant Gonorrhoea
Yesterday, I blogged about the fact that TB is on the rise worldwide. Funding for TB prevention, and even for treatment, are not commensurate with the threat to global health that this epidemic poses. And the rise of TB is often blamed on the current HIV pandemic. I would suggest that there is a TB epidemic of a level that can not wholly be explained by the HIV pandemic and that, like almost every disease and health issue aside from HIV, TB is being ignored.
Those heavily involved in the HIV industry, such as Michel Sidibe, the head of UNAIDS and Michel Kazatchkine, head of the UN Global Fund for HIV, TB and Malaria, deny that high levels of HIV funding have starved other diseases of cash. Kazatchkine claims that 'over a third of of overall funding of the Global Fund is actually going to strengthening health systems'. I don't know how he came up with this estimate but it seems to me that there are only certain aspects of health systems that are benefitting from HIV cash, and those aspects relate to HIV.
Kazatchkine says the money is not just going on condoms and drugs. I sometimes wonder if the money is even going on condoms, along with the logistics of ensuring that people use condoms all the time and properly. Even the claim that a lot of money is being spent on drugs can seem hollow when people supposed to be taking them often cannot do so because of lack of food. And 20% of the new HIV cases in Kenya every year come from vertical infection, from mothers transmitting HIV to their babies.
Treatment of people with HIV may well have exceeded expectations. And I would like to see every HIV positive person who needs treatment receiving the drugs and support they need. But since the recent expansion of HIV treatment, millions more have become infected. Prevention has been forgotten about. People like Kazatchkine and Sidibe like to argue that distinguishing between treatment and prevention is a false dichotomy, but this is not so. If treatment played such a huge role in preventing further infection, transmission rates would be much lower than they are. In fact, the majority of people in Kenya who are HIV positive do not know their status. Perhaps there shouldn't be a dichotomy between treatment and prevention, but there is.
And if you think the programmes to teach people about safe sex and to persuade them to use condoms have been successful, consider the figures for preventable and treatable sexually transmitted infections (STI). There are an estimated 340 million new cases of curable STIs every year. This is after over 20 years of preaching about safe sex in every country in the world. If people were practicing safe sex, transmission of most STIs would also be reduced. Prevention involves taking steps to ensure the infection is not transmitted. In the case of STIs, that could involve the correct use of condoms, minimally.
HIV treatment and care has received much of the money available for the disease. Kenya's official strategy papers make this quite clear. Prevention has received very little money and has been pretty unsuccessful, with 5 new infections for every two put on HIV treatment, globally. And HIV has been treated as if it's just an easy matter to round up people and give them some drugs. As a result, there is growing resistance to the few HIV drugs available in developing countries. This can be compared to TB, where it has long been recognised that you can't just send people away with some drugs and expect them to take them religiously for 9 months and never see them again.
If health solely involves treating sick people, how will you ensure the continuing health of those who are not (yet) sick? In the field of sexually transmitted diseases, gonorrhoea is now also developing resistance to the most commonly available drugs. There has been little recent research into alternative treatments for gonorrhoea (or TB) because, I would suggest, most of the money has been spent on other 'priorities' (Oh, and big pharma are waiting for public funding for their research, a very important component for these (private) companies). One of those priorities is HIV and despite ploughing a lot of money into condoms and safe sex campaigns, prevention has not received the level of funding it needs.
Yet more evidence of the lack of success of HIV prevention work is the level of pregnancies among women receiving HIV treatment. Women with untreated HIV have far lower fertility levels, so treatment should increase fertility. But women on HIV treatment should also be receiving advice about having unprotected sex and about unplanned pregnancies. I don't believe that all these HIV positive women are choosing to have more children, though some of them may be. Because other research has shown that the vast majority of pregnancies among women who are HIV positive were not planned.
Sidibe even seems to think that the global recession and climate change are distractions to the industry's fight against Aids. I would be hard pressed to find an attitude to which I am more opposed. He even has the cheek to suggest that HIV funding has not led to the neglect of other diseases because it has increased attention for TB, the two diseases being 'integrated', and that HIV prevention should take on a 'holistic approach'. Damn right, but I don't think his use of 'holistic' is the same as mine. But when is all this HIV money going to be spent on the many health issues that I and many others would claim have been ignored? Apparently, Sidibe and Kazatchkine think that's already taking place, and Sidibe feels that support from the big pharmaceutical companies is essential. Very funny.
Monday, March 29, 2010
TB on the Rise: Big Pharma Delighted
Although TB is often mentioned along with HIV, it doesn't get nearly as much attention, certainly not as much attention as it deserves. And it gets a fraction of the funding. It happens to be in the news now because World TB Day was just last week. Unlike HIV, TB is easier to catch but also easier to prevent. It's also curable. But like HIV, TB spreads rapidly in populations which face serious and long term economic challenges, have poor and inaccessible health systems, low educational standards and an inadequate infrastructure.
Like HIV, TB will not be eradicated until the determinants of health are tackled. Like HIV, you can spend as much as you like on the disease but as long as people live in terrible living conditions without even basic water supply and sanitation, suffer from poor health and nutrition and face many other stresses that allow any diseases going to spread rapidly, neither will be eradicated. The huge amounts of money spent on HIV over the last three decades has done little to reduce its spread and the far smaller amounts spent on TB have been equally unsuccessful.
Kenya ranks 13th in the 22 high burden TB countries and fifth in Africa, although it is notable that they are only rank 9th for HIV. There were 132,000 new cases last year. It is estimated that there were 2000 multiple drug resistant cases but only 4.1% of these were diagnosed. And only 48% of new TB patients were coinfected with HIV. New cases of TB are declining but the number requiring retreatment, those who either weren't treated successfully or who didn't finish their treatment, is increasing.
I think it is important to note that just over half of the new TB cases were not people who also have HIV. TB is an epidemic in its own right. While high HIV prevalence will increase the spread, TB is spreading independently of HIV too. And why wouldn't it? Most people in Kenya live in the sort of conditions where all diseases spread rapidly. Just as HIV has been treated as if it is exceptional and as if it is possible to eradicate a disease without also dealing with the determinants of health, TB is being treated as if people's living conditions don't matter. But they do matter, very much.
Jeffrey Sachs points out that if Africa had better health systems, HIV would have been identified a decade earlier. This is quite true, the symptoms that were later recognised as those of Aids were not recognised as being out of the ordinary. They were consistent with very poor health, poverty and malnutrition. It was only when people in more developed countries started to be infected that HIV and Aids were identified. By then, it was too late to avert a massive epidemic. Then, as now, the conditions in which people lived were appalling.
Nigeria has an even more serious TB epidemic, third in the world, with 100,000 new cases last year, although they only rank 21st in the world for HIV (despite being estimated to have the second highest number of people living with HIV, after South Africa). Rwanda and Malawi have the highest rates of TB in the world but Rwanda, at number 14 and Malawi, at number 8, certainly don't have the highest rates of HIV. The point I'm trying to make is that in developing countries, conditions are poor and declining but also, are not being remedied by the pouring of funds into programmes that merely treat sick people (ok, a small amount goes into prevention, but not much).
Aside from neglecting the determinants of health in general, programmes for TB and HIV are mainly targeted at people who are already sick. Most of the money goes to treating people who are already infected. Preventing both HIV and TB has a lot in common, indeed, preventing all diseases has a lot in common. People need good living conditions, water and sanitation, education, health, employment, economic well being, good nutrition, food security and many other things. Instead, most of the aid money going into these diseases is spent on drugs and other technologies.
PRWeb has a cringe-making release about a report on TB theraputics (which costs $3450, in case you are interested. This release enthuses about the "excellent commercial opportunity for existing as well as new companies in this marketplace." The "marketplace" is certainly growing, because if the only solution to TB is to wait until people become infected and then treat them with drugs, resistance is only a matter of sitting back and waiting. People in developing countries with TB are given the drugs and sent home to continue spreading it in their inadequte housing and with their poor nutrition and lack of education and water and sanitation.
These pharmaceutical companies have been humming and hawing because public funding hasn't been forthcoming but now that it looks like that will be made available, they can start raking in the cash. Remember, that's public funding, because the profits certainly won't be public.
All the conditions for the rapid spread of TB are in place and many of them are the same conditions for the spread of HIV. Little has been done to alleviate these conditions and in countries like Kenya, they have been steadily disimproving for several decades. It may be popular to blame the HIV epidemic, for TB and just about everything else that's happened since the 1980s, but this excuse won't wash. Winding down public services and public spending started before HIV was even identified. TB was around before HIV was identified. The opportunity to eradicate TB is still there, but throwing a lot of drugs and money at it will continue to fail.
Developing countries need to be enabled to develop. Diseases are not just inconvenient pathogens that can be eradicated with some extremely expensive drugs. They require an appropriate environment and suitably weakened hosts. Current and past approaches to TB and HIV ignore the existence of appropriate environments and weakened hosts aplenty. That's why HIV and TB are spreading, despite the billions spent on them.
Wednesday, December 3, 2008
Centres and Peripheries
The trip back from Mumias to Nairobi was long, hot and often bumpy. But there were no incidents, flat tyres, etc. Only the usual poorly surfaced roads and traffic jams in Nairobi. It’s only about 350km so nine hours is slow, but not the worst.
Infrastructure is a big problem in Kenya and East Africa in general. So many projects assume a certain level of telephone, mobile, rail and internet connections and quickly run into difficulties.
For example, there are hundreds of internet cafes in Nairobi but try to find one where you can do everything you need to do online and you may have difficulties. I tried today for three and a half hours and just as I was about to compromise and try to achieve only some of my objectives, there was a power failure throughout the city. How long it will last is anyone’s guess.
There is a tantalising possibility that the poor roads in Kenya, Tanzania and other countries played a part in protecting many people from becoming infected with HIV early on in the epidemic. People in more isolated areas were not infected in large numbers in the early years.
However, that is not the case any more. As mentioned in the last few days, people in rural areas and more isolated areas in both Kenya and Tanzania are being infected now in greater numbers than before. They are not receiving the prevention education that is sometimes found in towns and cities and testing facilities are scarce or non-existent.
Countries with relatively good infrastructures sometimes have much higher HIV prevalence than Kenya or Tanzania. Examples of this phenomenon are Zimbabwe, Malawi, South Africa and Botswana. Of course, there are probably other reasons why HIV prevalence is so much worse there, but demographic balance, mobility and circular migration play an important part in the transmission of HIV.
One of the reasons why urbanization may be so strongly associated with high and fast transmission rates of HIV is the high number of males in urban populations. Botswana, one of the richest countries in Africa, with one of the highest rates of HIV in the world, has also experienced rapid urbanization, economic growth, population growth, high levels of income inequality, a history of mobility and high levels of commerce with surrounding countries.
Botswana's economy depends to a large extent on extractive industries and they, typically, employ large numbers of men who live in all-male accommodation. This results in high levels of commercial sex and a consequently increased risk of contracting and spreading HIV and other STIs.
Employees are not just from Botswana, so when they return home, they can transmit HIV and other conditions to their home countries, which are often poor, with high unemployment rates.
Ok, Kenya doesn’t have a lot of mining, certainly not on the same scale as Botswana. But there are industries that give rise to circular migration and the resulting demographic imbalances and consequent spread of HIV and other diseases.
Kenya’s number one product is tea. As mentioned, Mumias is dominated by the sugar industry. Some coastal areas grow little but sisal. And there are natural resources here, such as soda and uranium. Other examples are the massive cut flower businesses around Lake Naivasha and the fruit and vegetable growing farms.
All these industries depend on large supplies of casual labour, very often for only part of the year. People arrive and stay for as long as the work lasts and then go back to their homes. Many of these economic migrants are male and they live away from their families for much of the year.
This kind of circular migration, often driven by rural poverty, is common in developing countries and is associated with many health hazards, for example, TB. Labour practices in South African diamond and gold mines result in similar conditions and again, the HIV related effects were transmitted to surrounding countries that suffered worse HIV prevalence than that of South Africa.
Eileen Stillwaggon, in AIDS and the Ecology of Poverty, talks of the “circular migrant streams” that are fuelled by mines, factories and plantations and the consequent slums and shanty towns with their poor sanitation and high rates of disease and malnutrition. It must also be noted that circular migration transmitted HIV from urban to rural regions in earlier years but later the transmission was in both directions.
John Iliffe, in A History of the African AIDS Epidemic, cites the “male predominance in urban populations” in East Africa as one of the reasons why levels of infection were higher there than in western equatorial Africa. In the early 1990s, “Kigali had 50 per cent more men than women aged 20-39” (page 21). In Nairobi in 1979 there were 138 males for every 100 females, the imbalance was even higher among adults and many of the males were unmarried.
A high male to female ratio in the population does not just affect urban dwellers. Fishing communities in rural areas around Lake Victoria were predominantly male and HIV rates there are very high. Nyanza province has the worst HIV rates in Kenya. Rural dwellers are also affected by these imbalances because the migration is temporary and people come and go, perhaps for much of their working life.
There are also certain occupations that involve high levels of mobility. Iliffe mentions urban immigrants, truck drivers, alluvial miners, their female partners and labour migration as examples of particularly mobile groups. Towns along trade routes often have higher rates of HIV than other towns.
This problem is especially prominent at borders. Border controls are very slow moving and truckers often have to spend several days in border towns because of slow administrative procedures. It can be cheaper for them to stay with a casual partner there than to put up in a hotel, so it’s an ideal place for commercial sex workers to look for business.
These are all major factors in the history of the transmission of HIV in Kenya and East Africa in general. They crop up constantly in the literature and mobile people were among the first ‘vulnerable groups’ to be studied, along with commercial sex workers.
It was Zimbabwe's “excellent transport system” and circular internal migration between urban and rural areas that transmitted HIV out into rural areas, according to Iliffe (page 39). In the case of Malawi, Iliffe makes a further connection between higher education and greater mobility, perhaps elucidating the phenomenon of higher HIV prevalence sometimes being associated with higher levels of education.
Iliffe tracks the transmission of HIV from Western Equatorial Africa to East Africa, Southern Africa and West Africa. He makes it clear that mobility is the chief driver of the epidemic at the regional level.
Indeed, obstacles to mobility from east to west is one of the possible reasons Iliffe suggests as to why West Africa's epidemic was less severe than that of some other African regions. Where HIV rates were high in West Africa, one of the principle drivers was mobility, especially among commercial sex workers.
Tantalising as it is to suggest that poor infrastructure reduces the spread of HIV, it is not really true. It is true, but trivially so, that complete isolation is a protection against HIV and any other transmissible disease. In reality, people are not completely isolated, even in the most remote parts of Kenya.
Isolation explains why HIV spread slowly to rural areas and more quickly and earlier in cities and densely populated areas. It also demonstrates the critical situation that many towns, villages and rural areas are in, right now.
The situation is critical because we really don’t know what HIV prevalence is in more remote areas. People there are less exposed to HIV prevention publicity, they have less access to health and other social services and especially, to voluntary counselling and testing centres.
The further people are from urban centres, the more isolated they are, the less we know about HIV rates in those areas. The difference in prevalence between urban and rural areas may be merely apparent.
Infrastructure is a big problem in Kenya and East Africa in general. So many projects assume a certain level of telephone, mobile, rail and internet connections and quickly run into difficulties.
For example, there are hundreds of internet cafes in Nairobi but try to find one where you can do everything you need to do online and you may have difficulties. I tried today for three and a half hours and just as I was about to compromise and try to achieve only some of my objectives, there was a power failure throughout the city. How long it will last is anyone’s guess.
There is a tantalising possibility that the poor roads in Kenya, Tanzania and other countries played a part in protecting many people from becoming infected with HIV early on in the epidemic. People in more isolated areas were not infected in large numbers in the early years.
However, that is not the case any more. As mentioned in the last few days, people in rural areas and more isolated areas in both Kenya and Tanzania are being infected now in greater numbers than before. They are not receiving the prevention education that is sometimes found in towns and cities and testing facilities are scarce or non-existent.
Countries with relatively good infrastructures sometimes have much higher HIV prevalence than Kenya or Tanzania. Examples of this phenomenon are Zimbabwe, Malawi, South Africa and Botswana. Of course, there are probably other reasons why HIV prevalence is so much worse there, but demographic balance, mobility and circular migration play an important part in the transmission of HIV.
One of the reasons why urbanization may be so strongly associated with high and fast transmission rates of HIV is the high number of males in urban populations. Botswana, one of the richest countries in Africa, with one of the highest rates of HIV in the world, has also experienced rapid urbanization, economic growth, population growth, high levels of income inequality, a history of mobility and high levels of commerce with surrounding countries.
Botswana's economy depends to a large extent on extractive industries and they, typically, employ large numbers of men who live in all-male accommodation. This results in high levels of commercial sex and a consequently increased risk of contracting and spreading HIV and other STIs.
Employees are not just from Botswana, so when they return home, they can transmit HIV and other conditions to their home countries, which are often poor, with high unemployment rates.
Ok, Kenya doesn’t have a lot of mining, certainly not on the same scale as Botswana. But there are industries that give rise to circular migration and the resulting demographic imbalances and consequent spread of HIV and other diseases.
Kenya’s number one product is tea. As mentioned, Mumias is dominated by the sugar industry. Some coastal areas grow little but sisal. And there are natural resources here, such as soda and uranium. Other examples are the massive cut flower businesses around Lake Naivasha and the fruit and vegetable growing farms.
All these industries depend on large supplies of casual labour, very often for only part of the year. People arrive and stay for as long as the work lasts and then go back to their homes. Many of these economic migrants are male and they live away from their families for much of the year.
This kind of circular migration, often driven by rural poverty, is common in developing countries and is associated with many health hazards, for example, TB. Labour practices in South African diamond and gold mines result in similar conditions and again, the HIV related effects were transmitted to surrounding countries that suffered worse HIV prevalence than that of South Africa.
Eileen Stillwaggon, in AIDS and the Ecology of Poverty, talks of the “circular migrant streams” that are fuelled by mines, factories and plantations and the consequent slums and shanty towns with their poor sanitation and high rates of disease and malnutrition. It must also be noted that circular migration transmitted HIV from urban to rural regions in earlier years but later the transmission was in both directions.
John Iliffe, in A History of the African AIDS Epidemic, cites the “male predominance in urban populations” in East Africa as one of the reasons why levels of infection were higher there than in western equatorial Africa. In the early 1990s, “Kigali had 50 per cent more men than women aged 20-39” (page 21). In Nairobi in 1979 there were 138 males for every 100 females, the imbalance was even higher among adults and many of the males were unmarried.
A high male to female ratio in the population does not just affect urban dwellers. Fishing communities in rural areas around Lake Victoria were predominantly male and HIV rates there are very high. Nyanza province has the worst HIV rates in Kenya. Rural dwellers are also affected by these imbalances because the migration is temporary and people come and go, perhaps for much of their working life.
There are also certain occupations that involve high levels of mobility. Iliffe mentions urban immigrants, truck drivers, alluvial miners, their female partners and labour migration as examples of particularly mobile groups. Towns along trade routes often have higher rates of HIV than other towns.
This problem is especially prominent at borders. Border controls are very slow moving and truckers often have to spend several days in border towns because of slow administrative procedures. It can be cheaper for them to stay with a casual partner there than to put up in a hotel, so it’s an ideal place for commercial sex workers to look for business.
These are all major factors in the history of the transmission of HIV in Kenya and East Africa in general. They crop up constantly in the literature and mobile people were among the first ‘vulnerable groups’ to be studied, along with commercial sex workers.
It was Zimbabwe's “excellent transport system” and circular internal migration between urban and rural areas that transmitted HIV out into rural areas, according to Iliffe (page 39). In the case of Malawi, Iliffe makes a further connection between higher education and greater mobility, perhaps elucidating the phenomenon of higher HIV prevalence sometimes being associated with higher levels of education.
Iliffe tracks the transmission of HIV from Western Equatorial Africa to East Africa, Southern Africa and West Africa. He makes it clear that mobility is the chief driver of the epidemic at the regional level.
Indeed, obstacles to mobility from east to west is one of the possible reasons Iliffe suggests as to why West Africa's epidemic was less severe than that of some other African regions. Where HIV rates were high in West Africa, one of the principle drivers was mobility, especially among commercial sex workers.
Tantalising as it is to suggest that poor infrastructure reduces the spread of HIV, it is not really true. It is true, but trivially so, that complete isolation is a protection against HIV and any other transmissible disease. In reality, people are not completely isolated, even in the most remote parts of Kenya.
Isolation explains why HIV spread slowly to rural areas and more quickly and earlier in cities and densely populated areas. It also demonstrates the critical situation that many towns, villages and rural areas are in, right now.
The situation is critical because we really don’t know what HIV prevalence is in more remote areas. People there are less exposed to HIV prevention publicity, they have less access to health and other social services and especially, to voluntary counselling and testing centres.
The further people are from urban centres, the more isolated they are, the less we know about HIV rates in those areas. The difference in prevalence between urban and rural areas may be merely apparent.
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