Unsafe Sex and Unsafe Healthcare are Mutually Exclusive HIV Risks in African Countries?

Recently, I blogged about a series of investigations that took place in various US states over a period of 10 years because of 86 cases of hepatitis C infection (HCV) being discovered, which could not be explained by the usual risks for this virus in a wealthy country, namely intravenous drug use and the like.

This extremely comprehensive investigation revealed that the 86 infections resulted from the actions of just six health personnel, who all had an addiction to controlled drugs. Over the course of 10 years they had put the safety of an estimated 30,000 patients at risk.

When a young woman in Brazil was found to be infected with HIV and no obvious sexual risks were established, rigorous research was carried out to discover a possible mode of transmission. The research found that the woman may have been exposed to contaminated manicure instruments many years before.

The manicure instruments belonged to the patient's cousin, who had been on antiretroviral drugs, but whose treatment had lapsed. Phylogenetic analysis showed that the patient had very likely been infected by this cousin, and that sharing contaminated manicure instruments was the most likely mode of infection.

Worryingly, the paper finds that "In a recent case of transmission among women, the CDC lists, along[side] classical transmission routes, potential alternative sources that must be ruled out, such as tattooing, acupuncture, piercing, the use of shared sex toys between the partners and other persons, and exposure to body fluids, but does not include manicure instruments."

The use of shared sex toys but not other shared instruments? Forgive me for thinking that people working for the CDC and other normative agencies may have some unresolved issues relating to assumed sexual practices, and perhaps an aversion to discussing non-sexual risks; or maybe that's just when it relates to African countries?

Although an estimated 70% of HIV positive people live in sub-Saharan Africa, the kinds of investigation that were carried out in the US and Brazil do not appear to have been carried out in any African country. At least, if they have been carried out, they have not been written up in peer-reviewed papers.

Anyone who has visited Kampala in Uganda or Moshi in Tanzania may have seen people with basins of manicure equipment being used in the open, in shops and other premises, on women waiting for buses, working, shopping or just taking some time for a manicure or pedicure.

In Dar es Salaam and other places you may see men shaving another man's head with a hand held, double edged razor. When one has finished, they swap around. Little nicks and cuts are usually treated with a piece of tissue, or possibly with a bit of antiseptic.

However, when people are diagnosed with HIV in African countries they are generally not asked about their possible non-sexual exposures, through unsafe cosmetic, traditional or healthcare practices. When people say they have not had sex, that they have not had sex with a HIV positive person, or that they have only had protected sex, these matters are generally dismissed.

HIV is not the only pathogen that is possibly fairly frequently transmitted in cosmetic, traditional and healthcare contexts, where skin-piercing is involved. Other pathogens include hepatitis, various bacterial infections, scabies, even ebola. Where skin-piercing is not involved, also, several serious diseases can be transmitted in these environments, for example TB.

It seems that, because it's Africa, sex is always imputed, even when the patient makes it clear that this may not be, perhaps even cannot be, the mode of transmission. Because it's Africa, unsafe healthcare, it seems that cosmetic and traditional practices can not explain otherwise inexplicable HIV infections.

According to normative agencies such as UNAIDS, healthcare and other environments are unsafe enough to explain high prevalence of hepatitis C in several low HIV prevalence countries, such as Egypt, but can't explain high HIV prevalence in a low HCV prevalence country, such as South Africa.

Why should healthcare be unsafe and sexual behavior safe in all and only the countries with high HCV prevalence in Africa, while healthcare is safe and sexual behavior unsafe in all and only the countries with high HIV epidemics? Also, if sexual behavior is so unsafe in sub-Saharan Africa, shouldn't HCV prevalence also be high all high HIV prevalence countries?

UK to Impose Gay Rights on Uganda While US Imposes Homophobia

Some may be disappointed by David Cameron's attempt to influence countries that make homosexuality illegal by threatening to cut off foreign aid. Uganda feels that Britain is bullying them and treating Ugandans like children, and I agree. I think homosexuals should be entitled to do whatever they do as long as it doesn't infringe on the rights of others. Nor do I think people expressing their sexuality in whatever way they choose constitutes an infringement on the rights of others.

But why should money that is supposed to be used to improve health, education, social services and infrastructure be used to threaten the government to pass legislation that suits current tastes in Britain? If aid is just a tool to get developing countries to become 'model states' in the eyes of Western countries, this is unlikely to work any better now than it has in the past.

Are Cameron and other Western leaders going to produce a list of desiderata, which can be ticked off as developing countries comply and be rewarded with another project, program, scheme or plan, and a handful of brownie points? The problem with aid in its current form is that it is not working very well. Some might say that is does work, it's just that it was never intended to work for developing countries, that the beneficiaries of foreign aid are the donor countries. That may be so, but what does that have to do with gay rights, or any rights?

Throwing money at the latest CNN moment, Aids, famines, earthquakes, hurricanes and tsunamis, is what it is, sheer posturing. But would Cameron and his fellow statespeople consider it acceptable to say to a country currently being devastated by a disaster, that aid money will be sent as soon as they improve their gender equality situation or their use of child labor (which is probably of far greater benefit to western countries than it is to developing countries)?

People here, and anywhere, can be whipped up into a frenzy about gay rights and all sorts of other things. But these are not the biggest day to day worries faced in poor countries. There's poverty, bad health, low educational standards, rotten infrastructure, inequalities of all kinds, failing governance, corruption and lots of other problems. Gay rights in Uganda are a political issue that can be milked for what it's worth or ignored, whichever political leaders and opinion makers choose at a particular time.

All Cameron is doing is adding to the frenzy. Instead of kicking someone for being gay, they can be kicked for threatening foreign aid monies. But no Ugandan politician, or politician of any country, is just going to back down and say, 'OK, we'll rewrite our legislation, sorry about that'. Bribing and threatening national administrations is not the way to change the attitudes of entire countries and it makes Cameron, and the UK, look stupid. It makes them look as if they don't really understand the concept of 'human rights'.

Cameron needs to go back to the drawing board. Threatening a country with suspension of aid, whatever kind of aid is involved, is not a way of bestowing rights on a population. Rather, it's just another way of taking away people's rights. No doubt, Cameron's tabloid reading supporters will be delighted, but he should keep his tabloid deplomacy for the UK, where he has a democratic mandate.

Interestingly, the BBC reminds us that "Some 41 nations within the 54-member Commonwealth have laws banning homosexual acts. Many of these laws are a legacy of British rule." The problem is not that former British colonies are refusing to be spoonfed, just that they now choose which of the spoonfuls to swallow and which to spit out.

What Cameron could do is go and have a word with his American puppet masters, who have done a lot to stir up the anti-gay fervor in the first place. But before that, he'll have to withdraw his idiotic remarks about withholding aid in return for 'gay rights' in Uganda. Otherwise, rights are whatever those paying the most say they are. Unfortunately, he's going to have to go through quite a transformation to follow this logic.

Uganda's HIV Epidemic: Mystery or Myth?

I have always worried about the way Uganda is held up as an example to other African countries on account of its early experience with HIV. What happened in Uganda earlier on is not the same as what happened later.

Early on in the epidemic, everything possible was done to reduce HIV transmission, both sexual and non-sexual transmission, in all their forms. Later, non-sexual transmission became more and more excluded and a set of myths about the efficacy of the ABC (abstain, be faithful, use condoms) strategy replaced any semblance of a coherent strategy.

The epidemic in Uganda took off earlier than in most other countries. HIV incidence, the rate of new infections, then declined and several years later, prevalence (the percentage of HIV positive people between the ages of 15 and 49) also declined.

It is not clear exactly why the epidemic took off when it did, nor is it too clear why incidence then peaked and declined. Measures to control the epidemic are likely to have played some part, of course, but how big a part has long been a matter of debate. Prevalence would have declined because of high death rates.

Once global HIV policy was thrown off course by ABC, or even AB or just A, it never got back on course. The burgeoning HIV industry's obsession with sex still rages and non-sexual HIV transmission, for example, through unsafe healthcare or cosmetic practices, is rarely talked about, let alone researched or investigated.

This leaves Uganda in a vulnerable position. The country receives a lot of HIV money, most of which is spent on drugs and care for HIV positive people. And the little left over for preventing new infections is spent on interventions that obviously don't prevent new infections.

Prevalence declines that resulted from high death rates have been reversed by a high rate of new infections. Those on treatment are likely to stay alive for longer, adding to increases in prevalence. But many HIV positive people still die, usually from treatable illnesses.

Not only is Uganda far from eradicating HIV, there is still a very serious epidemic in the country. Prevalence is bumping along, lower than it was during the worst years, true, but it has hardly changed for the last 10 years.

Infection rates in young people is often seen as a proxy for incidence because it's hard to measure incidence directly. But if young people who are just becoming sexually active are infected in large numbers, the epidemic is still very much alive. And 1.5% of people between 15 and 19 are HIV positive, 2.6% among girls and 0.3% among boys.

Of course, many of these teenagers could have been infected by mother to child transmission. But it's unlikely that they all were, unless this type of transmission is a lot more common that has been realized.

We are told that the highest burden of HIV, though, is now among married couples between 30 and 40 years old. In fact, it has been realized for some time that the majority of transmissions in Uganda appear to be a result of sex that is not 'unsafe' by any of the HIV industry's definitions.

HIV is common among those who don't have sex very much, are not likely to have several sex partners, and most of whom only have sex with a long term partner. Many, also, are in discordant relationships, their partner is not infected (or they did not infect each other). And half of the infected partners are female, so there goes the 'all men are promiscuous' theory of HIV transmission.

And that's the problem. If HIV is not primarily transmitted through unsafe sex, interventions that target unsafe sex will have little effect on transmission rates.

Yet the conclusion of Uganda's Ministry of Health is that they should encourage male circumcision, increase use of female condoms and awareness about HIV/AIDS. This may or may not reduce sexual HIV transmission. But after so many years watching HIV transmission stagnate, so many people becoming infected and so many dying, perhaps they could think about changing tack.

HIV is difficult to transmit sexually, yet it seems to be transmitted very rapidly in Uganda. Young people who are just starting to have sex are being infected quickly, which suggests that we are way off when it comes to our knowledge of transmission probabilities. Or perhaps not all HIV is transmitted sexually? Either way, we need to find out why transmission rates are so high in Uganda. Otherwise it will not be the only country with stagnating HIV prevalence figures.

Pre-Exposure Prophylaxis, Till Death Do Us Part

Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. So far, such a use of ARV does not give 100% protection. However, like male circumcision and the use of topical microbicides, it could be used along with condoms. Or you could just use condoms.

But the ultimate aim is to develop PrEP that allows people to have safe sex without using condoms (otherwise they will tempt very few). Cynics even suggest that the aim is to allow men who have sex with men (MSM) in rich countries to have unprotected sex, but I don't quite buy that.

The fact that a lot of the clinical trials are taking place in developing countries doesn't mean the people there will eventually benefit from PrEP. But to the pharmaceutical companies that sell ARVs, developing countries represent a huge potential market. That's as long as donors can be persuaded to pay for the drugs. Costs are far beyond what people or governments in developing countries can afford.

There are many questions to be raised about how much the use of PrEP could really help reduce HIV transmission. But my question is about who, exactly, would be the targets of a PrEP program in developing countries, taking Uganda as an example (because I happen to have the Ugandan Modes of Transmission Survey handy).

You might think an obvious target for PrEP would be sex workers. But in the 2009 survey, Ugandan sex workers were estimated to contribute 0.91% of HIV incidence. If you add in their clients and the partners of their clients, that still only comes to an estimated 10.5%. PrEP rollout for these groups, assuming you could actually round them all up, would be very expensive. But it doesn't look like it would have much impact on the overall epidemic.

The largest single group, contributing 43% of total incidence, consists of mutually monogamous couples engaging in heterosexual sex. Bizarre as it may sound, most HIV in Uganda, a virus that is difficult to transmit sexually, is transmitted by very low risk sex.

Those engaging in multiple partnerships, along with their partners, make up 45% of incidence, so perhaps they would be good targets. Again, it would be a mammoth task to round up such a large number of people, let alone distribute drugs to them all and ensure that most of them took the drugs most of the time for as long as they continue to be sexually active.

Think of it this way, Kenya has several hundred thousand HIV positive people on ARVs, that's less than 1% of the population. Around 99% of that money comes from donors. And even that few hundred thousand people is beyond what the countries health services can manage, despite all the donor funding.

The sad truth is that, either you 'target' much of the sexually active population of Uganda, which is not really targeting, more scattergunning, or you will not have any sizable impact on the epidemic. But PrEP is simply not the sort of intervention that you can roll out to a large sector of your population.

An article about the costs involved in rolling out PrEP in Australia cites very high costs just for basic, first line drugs. At up to and beyond 10,000 dollars per person, for the rest of their life, this will not even be discussed in developing countries. And while the drugs will be available at far lower cost in places like Uganda, you are talking about millions of potential recipients. Resistance to first line drugs may only amount to 3 or 4% (if they are lucky) but you can multiply that five or ten times to calculate the addition to costs.

The drugs will be available at far lower prices because drug companies have an uncanny way of knowing just how much they can squeeze out of a 'marketing' situation. Rich countries will pay hefty sums for worthless drugs, or drugs worth very little but in huge quantities. Just look at Tamiflu and the stockpiles of it. They will pay less to purchase drugs for developing countries, but the quantities will be mind boggling and Western run institutions will agree to any price once it's in the hundreds of dollars, apparently.

Talking of Tamiflu, one of the main proposed PrEP drugs is Tenofovir, discussed in glowing terms and voluminous quantities during the Vienna Aids Conference. Another is called Truvada, a combination drug. Gilead is involved in all three.

Another name that crops up is Bill Gates and his Foundation, who are never far away if there is money to be made out of intellectual property. But what will the benefits of PrEP be? If Modes of Transmission Surveys like the one for Uganda are correct, almost everyone that has sex in high and medium HIV prevalence countries is at risk. They can't all be put on preventive drugs, even if it were possible to afford such an intervention.

It may sound as if I am claiming that an almost entirely useless HIV prevention strategy is being advocated for by the very pharmaceutical industry that stands to gain billions from it. And that's exactly what I am claiming. Big Pharma expect billions more dollars, on top of the billions they have already received, to flow from persuading donors to pay for up to tens of millions of healthy people to be put on drugs for a large part of their life, with little or no benefit and possibly a lot of damage. In a nutshell: pre-exposure prophylaxis or PrEP. Remember the name.

NB: I have set up a new blog to discuss the subject of pre-exposure prophylaxis or PrEP.

Discovering Poverty

Only a few months ago there was great excitement about the 'discovery' of oil in Isiolo, in Kenya's Eastern province. This is not the first time oil has been 'discovered' there. Tens of millions of dollars have been poured into exploration without any commercially viable discovery. A few hundred thousand dollars were put into making local people think that they will benefit from being an oil producing region and no money at all went into cleaning up the pollution and environmental damage caused over the years.

A local politician was predicting that "Kenya will join Uganda in celebrating the status of a new oil producer". So far, Kenya is not celebrating. But neither is Uganda, despite discovering huge quantities of oil. This is not a new story of developing countries having enormous mineral wealth while their own people make nothing and lose a lot. It's the same old story of Nigeria, Sudan, South Africa, Botswana, Tanzania, Uganda and, indeed, Kenya. There's no reason why the story should change, as long as wealthy countries can get hold of all the oil and other resources they require.

As Uganda is finding out, deciding who gets to profit from the oil deposits is not up to them. It's up to their senior politicians, a handful of business people and a bunch of rich foreigners. If anyone who doesn't belong to one of those groups happens to have property or interests affected by work of extracting oil, that's their tough luck. Sure, some people will be employed for a while, but most of the top jobs will go to foreigners or to people who are already pretty well off. A hell of a lot more people will lose their livelihood, most of them being subsistence farmers and others who are just getting by.

Local consultation, democratic accountability, sustainability, environmental impact, social impact, these are all as relevant as condoms at a USAID sponsored HIV awareness programme. Tullow Oil and that bastion of corporate social responsibility Royal Bank of Scotland will be able to wallow together in their ethical vacuum without having to worry about petty matters like human rights, environmental contamination or mass evictions of people from their land. And no one need worry, the Ugandan government will compensate the oil company if anything threatens their profit margins.

Kenya should note what's happening in Uganda at the moment. Not that their politicians are likely to behave any differently if oil is discovered here. But maybe civil society groups here can start now, before the sort of secret negotiations seen in Uganda get going. It's hard to imagine what a developing country successfully extracting a natural resource would look like, where people in that country actually gained from the process rather than suffering greater poverty, disease and death.

Maybe oil will not be discovered in Kenya, or perhaps not yet. It's not that natural resources are a bad thing, but as long as developed countries and multinationals always have the upper hand when they are discovered, the resources might as well remain in the ground. Some Kenyans may not know how lucky they are, but many in Isiolo would still remember the fallout from the various explorations and 'discoveries' of the last few years.

Compulsory HIV Testing for Pregnant Women is Counterproductive

It's probably a good thing that Uganda has merged the provision of sexual and reproductive health with HIV programmes. It remains to be seen whether they do a good job of it and the fact that both functions will still be provided by two different government departments doesn't bode well.

But the proposed introduction of mandatory HIV testing for pregnant women is worrying. Most countries in the world have considered mandatory testing at some time and many have resisted it. The WHO has opposed it and, as far as I know, continues to oppose it. Not only is it considered to be a human rights abuse, but it is also thought to be counterproductive.

If it is a human rights abuse to carry out mandatory testing for specific groups for any disease, then it is an abuse to single out pregnant women for HIV testing. One of the dangers is that fewer women will attend ante natal clinics, with potentially disastrous consequences. But at present, Uganda is not providing ante natal care for all pregnant women. Will they start to provide it? Where will they get the money? And will ante natal care become mandatory too?

All people have the right to medical care, to treatment for illnesses, prevention of diseases, general health, reproductive and sexual health, etc. But what Uganda is proposing is that it will no longer be a woman's right to choose to be tested for HIV if she is pregnant, nor will it be her right to choose whether to be treated or not, nor will it even be her right to keep her HIV status confidential.

Ugandan health and social services are not able to cope with current levels of HIV, they have had constant problems testing people, treating people and maintaining supplies of medication. The country's health services function poorly and wouldn't function at all if it wasn't for high levels of donor support. But someone has now decided to make it even less likely that a large and vulnerable section of the population will seek health care just when they are most vulnerable. It is not just the pregnant women who are put in danger by such a proposal, it is also their unborn babies, perhaps their children, their partners and others.

The Ugandan government is not able to guarantee the safety of women who have been diagnosed as HIV positive. It is not able to guarantee that they will not be rejected or even persecuted by family and neighbours. It is not even able to guarantee that women will get adequate care to live a healthy life and raise their children to be healthy and strong.

HIV testing needs to remain an option to all people, including pregnant women. It needs to remain something people freely choose, something to which they can give their informed consent. That means they need to be counseled and advised before testing and supported after testing. This is the only way to ensure that the maximum number of people will agree to be tested for HIV. It is also the only way to support people in continuing to live a healthy and peaceful life in their own community and to take every step to avoid infecting others.

Compulsory HIV testing will not stop HIV from spreading. It will only make people fear testing, especially those most likely to be infected. Compulsion will result in the very people who most need to be tested avoiding testing centres and any place else where they may have to face a test, such as ante natal clinics and hospitals. Then, by the time people infected with HIV are identified, they may already be at an advanced stage of the disease and may well have infected many others.

The Ugandan government needs to encourage women to attend ante natal clinics when they are pregnant, not compel them to do so. People, whether pregnant or not, need to be advised to know their status, with regard to HIV and any other transmissible disease. If there is any chance of influencing people's sexual and reproductive behaviour, it is more likely to be achieved through education and support. It will certainly not be achieved through coercion, as Uganda and other countries have already spent nearly three decades finding out.

Uganda Won't Allow Mere Principles to Compromise Foreign Aid

Uganda's President Museveni is not known for being forbearing or fair minded, especially when it comes to men who have sex with men (or, presumably, women who have sex with women). But he has decided to distance himself from David Bahati's bill, which proposes the death penalty for certain offenses relating to homosexual behaviour and prison sentences for others who fail to report homosexual behaviour. It even proposes life imprisonment for persons engaging in same sex relationships.

This is not an instance of Museveni suddenly becoming softhearted, either. There are existing Ugandan laws against homosexuality with very long prison sentences. The country that claims to have had so much success in fighting the HIV epidemic continues to fail some of the people most at risk of becoming infected with HIV and of infecting others. Bahati's bill was certainly heading in the wrong direction but Museveni needs to do a lot more than oppose the work of a power crazed bigot.

Sadly, the Bahati bill had a lot of popular support in Uganda. Other East African countries have similarly punitive laws and there was the fear that if Uganda passed such a law, other countries would follow. It's frightening that most African countries outlaw homosexuality but even more frightening when you hear about the level of persecution homosexuals and those suspected of being homosexuals must put up with from the public, professionals, officers of the law and just about anyone else.

Museveni is said to have been reacting to international protests, especially from countries from which large amounts of donor money come. He mentions pressure from Canadian, American and British leaders and refers to the bill as a 'foreign policy issue', which it clearly is not. It's good that Museveni has decided to question the bill, but it would be more heartening to hear that he had some objection to persecution of and discrimination against homosexuals.

However, earlier on in the debate, people like Bahati said the country should forgo some foreign aid if donors objected. The debate has moved on a little and there was probably never any danger of Uganda refusing foreign aid. Their HIV efforts, and those of most high prevalence African countries, are almost totally dependent on foreign donations. But even some of the American fascist evangelists who originally supported the bill have now started to criticize it.

The best we can hope for right now is for Museveni to succeed in persuading Bahati to withdraw the bill or in persuading people not to support it. That would put Uganda back in the position it is in now with regard to homosexuality. That's not good, but it could be worse. But more pressure is needed, like the pressure against the Bahati bill, in order to ensure that the rights of homosexuals and other minority groups are recognised.

All the talk about Ugandan's and other Africans being so Christian, right minded, conservative and the rest is just so much posturing when you view it alongside people's attitudes towards those who are seen as somehow different. There's something scary about a religion whose adherents seem to behave in ways that are directly contrary to the religion's preachings.

To the Ugandans and other Africans who argue that homosexuality is an export from the West, it could be pointed out that the sort of double standards that allow avowed Christians to persecute their fellow human beings may actually be the worrying export from the West. These double standards are doing and will continue to do a lot of damage; unlike homosexuality, which has always existed in all known human societies, including African ones.

And Museveni has the cheek to talk about not compromising the country's 'principles', while at the same time taking into account 'foreign policy interests', presumably referring to hundreds of millions of dollars of aid money. Yes, it would be totally unchristian to do otherwise.

Homosexuality: Uganda Scores Another Own Goal

Uganda is busy going the wrong way again in their 'fight' against Aids. Parliament will discuss a bill to create even more offences that gay people can commit. It's already an offence to have a sexual relationship with someone of the same gender. The 'offence' will carry a seven year sentence, as will aiding, abetting, counselling or procuring another to engage in acts of homosexuality.

HIV/Aids and sexual rights activists feel this sort of law will make HIV prevention, treatment and care services even less accessible that they currently are. No one is going to admit to being gay or to risk being exposed as being gay even under current circumstances. No one wants to be stigmatized or discriminated against, however unfairly.

There is even a proposed death penalty for sexual assault against someone of the same gender who is under 18 or disabled. But sexual assault against anyone should always be against the law, as should sexual assault against someone who is below the age of consent, male or female, same sex or otherwise. Ugandan law considers sex between people of the same gender to be against the laws of nature. If anything is against the laws of nature, it is for a homosexual to have heterosexual sex. But what law is homosexual sex supposed to be breaking? Are these laws written down? I don't think so.

Ugandan laws would be better off protecting vulnerable people, especially children, improving the status of women, targeting those who are most at risk and removing barriers to prevention, treatment and care services instead of creating new laws that make those services less accessible. The law could also give a bit of attention to reining in the power of leaders who appear to have gone crazy. And reducing the number of people who live in extreme poverty would also be a good thing.

Sex itself is neither moral nor immoral. There is no moral argument that shows that homosexual sex is immoral, only an arbitrary judgment. Punishing people for behaviour that is not immoral and creating laws to legitimise this punishment, that is immoral. The law in Uganda is being misused to serve the interests of those who make arbitrary judgments about morality. Stigmatizing and discriminating against people, which supporters of this bill are doing, is immoral and should also be punishable by law.

Compulsory HIV Testing is a Bad Idea

The Ugandan parliament is discussing the possibility of making HIV testing and counselling compulsory because infection rates are continuing to rise.

In addition to being extremely difficult achieve, compulsory testing is also inadvisable. The very groups of people who are most likely to have high transmission rates will also be most likely to avoid being tested. Individuals who think they are likely to be infected may try to avoid testing because they fear the consequences.

The same groups of people that were being stigmatised in Uganda when the HIV epidemic started are still stigmatised now, commercial sex workers, intravenous drug users, etc; some are now under even greater pressure to hide from the law, for example, men who have sex with men (MSM).

Yet another reason for not testing is the possibility of being prosecuted for knowingly transmitting HIV. Women are especially vulnerable to this phenomenon because they are usually tested for HIV when they are pregnant. On the other hand, men usually don't get tested until they are showing symptoms that may suggest they are HIV positive.

It's good to hear that the Ugandan government is facing up to the fact that HIV is still a big problem in the country, rather than basking in the praise it once received for fighting the epidemic. But it would be a shame to see the country going down the route of returning to the sort of conditions that allowed HIV to spread in the first place.

Use Condoms and Get Tested, Regularly

Uganda has launched a new HIV/Aids campaign, ‘Stay Negative and Love Condoms’. That’s good to hear because condoms are vital for preventing HIV. There are lots of other things that can be done but a campaign that highlights the use of condoms is certainly preferable to ones where abstinence and faithfulness are stressed and condoms hardly mentioned. It’s also good to hear that some effort is being put into preventing transmission of HIV, rather than concentrating mainly on people who are already infected. The Aids Healthcare Foundation is running the programme so I’ll be watching out for further information on it.

In addition to emphasizing abstinence and faithfulness at the expense of prevention strategies that have any chance of working, the Ugandan government hasn’t been pulling its weight in its HIV prevention efforts. Research shows that people’s sexual behaviour is not very heavily influenced by recent campaigns for safer sex. Perhaps now they will look beyond sex, at people’s livelihoods and circumstances, which determine when, where, how often and with whom people have sex. While they are at it, they could work on their attitude towards men who have sex with men (MSM).

Currently MSMs are pretty much ignored by HIV prevention campaigns and they continue to be the victims of persecution and abuse. They are a very high risk group and this abuse only makes matters worse. They need the protection of the law and access to health services. As do commercial sex workers and intravenous drug users. Criminalization and the continued refusal to engage in meaningful harm-reduction efforts for these groups are senseless and appears to be motivated by political or religious interests (if these are in any way different).

Indeed, many countries are considering some kind of law making it a crime to knowingly transmit HIV. People who are infected with HIV need to be identified by voluntary testing, not hounded and criminalized. In addition to the use of condoms, testing is a vital and effective tool in HIV prevention and care. People need to be encouraged to test, not threatened with a prison sentence if they turn out to be HIV positive. This sort of law is particularly hard on women, who are more likely to test at an earlier stage in the disease. The more people who test early and regularly, the better.

It is things like stigma, persecution, gender and economic inequalities, poor legislation and enforcement, corruption and political and religious interference that have allowed HIV to spread rapidly in many countries. These problems are, in most countries, getting worse. This is not the time to pass laws that make HIV eradication even less likely than it is at present.

Use Condoms, get tested, regularly, be careful and advocate against discriminatory and harmful laws.

Don’t Face the Issues, Just Criminalize Them

Uganda is presently discussing an anti-homosexuality bill. Same sex relations are already against the law in Uganda (although same sex relations between females is not mentioned). The bill being discussed doesn't just ban same sex relations, it also bans publishing and distributing literature on homosexuality or 'advocating' for it.

There seems to be an assumption, which is far from uncommon, that people who have same sex relations actively 'recruit' people who would, if left alone, have remained heterosexuals. I find that assumption peculiar. It suggests that if those politicians, journalists, religious leaders and others who rail against same sex relations, could have turned out to be homosexuals themselves if they had been subjected to the influences of such 'recruitment'.

The minister for 'ethics and integrity' was interviewed on the subject and he seems to lump together "homosexuality, pornography, prostitution, human sacrifice, drug abuse, embezzlement and witchcraft" and feels that these are symptoms of society becoming permissive. Perhaps this minister should go back to school and learn to make very basic distinctions between what are very different concepts. But, sadly, I think he is just lacking in the sort of simple logic needed to engage in everyday life.

The issues he lumps together range from rare but horrendous crimes to common but undesirable ones. But he doesn't give any justification for his belief that homosexuality should be seen as a crime. Same sex relationships usually involve consenting adults. Not all sexual relationships involve consent and this is rightly seen as a crime, whether same sex or heterosexual. Pornography has many victims, as do prostitution and drug abuse.

Human sacrifice and witchcraft (aside from the mere suspicion that someone is a 'witch'!) are subjects that I am not able to comment on. But I should hope that human sacrifice is always punishable by law and that witchcraft is if it results in the breaking of laws.

But as for embezzlement, I wonder why the minister mentioned this crime. I can see why it is a crime but he seems to be worried about Uganda becoming a permissive society. Permissive societies do not permit embezzlement, not that I know if, anyhow.

The effect of criminalizing same sex relationships will give rise to discrimination against people engaging in them and against those thought to engage in them. It will increase the risk of crimes being committed against them. Surely, Mr Minister, you are opposed to crime and you would not wish to put forward legislation that will encourage it?

When it comes to preventing HIV transmission, criminalization of same sex relationships will make it more difficult to protect men who have sex with men (MSM). MSM are very vulnerable to being infected with HIV and are more likely to transmit it than those engaging solely in heterosexual relationships.

But this means that it must be made possible for MSM to be open about their sexual practices. If they are not open about their sexual practices it will not be possible to target this group with appropriate HIV reduction programmes. They will do everything they can to remain invisible, they will not be able to seek medical attention safely, they will not be protected by the law; they will become even more vulnerable than they are now and they will represent a greater obstacle to reduction of HIV transmission.

But I don't want this to be an argument for decriminalizing same sex relationships just because it helps control HIV. I simply don't think having sex with a person of the same gender should be seen as wrong. Of course it's wrong if one party doesn't want to take part but that should already be outlawed by laws against rape and sexual assault.

Clearly, prostitution and any kind of sex in exchange for goods, services, favours or whatever, is being entirely different. But criminalizing transactional sex (instances of it that are branded as 'prostitution', not all transactional sex, that would be impossible!) also faces the same problems as criminalizing same sex relationships, listed above. People involved in transactional sex, the ones this minister proposes punishing, are vulnerable. He is proposing making them far more vulnerable than they are already.

This minister for 'ethics and integrity' seems to have a serious problem with sex and sexuality and I don't think he is the most appropriate person for this ministerial brief. But perhaps he can learn; who knows? Perhaps his problem is with people who he sees as 'not like him'? Maybe he is a very praiseworthy man, morally, and thinks that everyone should be like him. But then he may be in for a surprise if he looks around his country, especially at his fellow leaders, political leaders, religious leaders, society leaders, etc.

The minister claims that people engaging in same sex relationships are abusing the rights of the majority. He is quite wrong, same sex relationships do not abuse any rights. On the contrary, he is trying to legalize the abuse of minorities. As for how many people in Uganda engage in same sex relationships? The present homophobic climate means that most people will not be open about their sexuality or about their opinion about the sexuality of others. The effects of his homophobia run deep and are long lasting.

As for the minister's call to religious leaders to 'fight immorality', he may wish to gen up on the record of some religious institutions when it comes to matters of sex and sexuality, even prostitution, embezzlement, pornography and other serious crimes. The trouble with people as perfect as this minister seems to be is that he may be in a very small minority himself.

Kenya's Neighbours, Uganda and Tanzania

How does Kenya’s HIV epidemic compare to those of neighbouring Uganda and Tanzania?

Well, HIV probably arrived first in Uganda, next in Tanzania and then in Kenya. After that, it took very different courses in each country. It spread quickly and rose to a peak prevalence of 14% in Uganda. It spread less quickly in Tanzania and peaked at below 8%. And, having started later in Kenya, it spread quickly and prevalence peaked at just over 10%.

As the graph below shows, there has been a gradual decline in prevalence in Uganda and in Tanzania. However, the decline in prevalence in Kenya reversed around 2004 and now stands at 7.8%, higher than it was back in 2002.



The next graph shows that death rates also have very different patterns in each country. Aids deaths started later in Kenya, as you would expect if HIV arrived later. But the number of deaths rose very rapidly and peaked at perhaps over 140000. This is far higher than Uganda and Tanzania, whose rates peaked at 120000.



Death rates in all three countries are now declining. One would expect this trend to be enhanced as anti-retroviral therapy (ART) is rolled out because this keeps more people living with HIV alive for longer.

The graph below plots the estimated numbers of people living with HIV and Aids. The rising number in Kenya is probably due to a combination of new infections and people living longer because of ART. The fact that the number in Tanzania is stable could be for similar reasons, except that there, the death rate is still pretty high. This is, of course, just one analysis and a quick and dirty analysis, for that matter. It’s possible that Uganda has a low rate of new infections at present; I don’t have access to recent figures.



Personally, I think the above figures alone can tell us very little about how the HIV epidemics stand in these three countries at the moment. I think the way HIV affects a country, how the epidemic spreads, waxes and wanes, depends on many things. Of particular importance are health and health services, education and literacy, various economic factors, social services, infrastructure and much else.

The annual Human Development Report collects national figures and uses them to calculate indices of various aspects of development. Thus, the gender development index shows inequalities between men and women in health, education and economic welfare; the life expectancy index shows the relative achievement of a country in life expectancy at birth; the education index brings together adult literacy and school enrolment; and the human development index (HDI) brings together health, education and economic welfare, being a composite of the education index, the life expectancy index and the GDP index. The GDP Index shows the gross domestic product per capita for a country.



There is a large amount of overlap among these figures, but they are all reproduced here to show how the three countries stand in relation to each other. From this chart, they would all seem pretty close together. In most cases, Kenya is a little better off than Uganda and Uganda is a little better off than Tanzania. If these factors also have an influence on the course a HIV epidemic takes in a country, each country’s epidemic may become more and more alike, despite their initial differences.

However, if you look at trends in the HDI (the only one for which historical trends are supplied), Kenya is not only out of step with Uganda and Tanzania, after being ahead of them for many years; Kenya’s HDI has also been declining for a long time. Over the same period, Uganda and Tanzania’s HDI has been improving.



Well, putting all these figures together doesn’t really put one in a position to analyse each country in sufficient detail to make predictions about what will happen next. Out of the three countries, only Kenya is seeing prevalence increase, after an initial improvement. It’s possible that Uganda and Tanzania’s prevalence are levelling off and will rise, but it’s hard to say.

However, a recent paper shows that prevalence is still increasing in Tanzania in more rural areas, though it is declining in less rural areas. Bear in mind, over 80% of people in Tanzania live in rural areas. Another paper suggests that the behaviour change that was said to have reduced HIV prevalence in Uganda substantially in the nineties and early 2000s is now reversing, that condom use is declining and unsafe sex is increasing.

Rural areas in Tanzania are less likely to benefit from HIV education, perhaps any education, from health services and other social services. And those in Uganda who are deciding to ignore the safe sex message, if the message is still being broadcasted, may need to be approached in a different way. What worked during a time of high prevalence followed by a time of high death rates, may not work now that the word ‘Uganda’ is usually accompanied by mentions of the country’s success in reducing HIV prevalence.

Among all the indicators relating to sexual behaviour that are collected by Demographic and Health Surveys, none show that one of the three countries is significantly ‘better’ or ‘worse’ than the other. These figures, even taken all together, don’t suggest why Tanzania’s prevalence never reached as high as Kenya’s or why Kenya’s never reached as high as Uganda’s.

Some health indicators show Tanzania to be in a far better position than the other two countries, despite public expenditure on health being lower. However, some of Tanzania’s health indicators are far poorer than the others. Other figures are very similar to those found in Uganda and Kenya. Education indicators are similarly mixed, though Kenya again has the highest level of public expenditure in education.

Some gender related figures do differ greatly. Kenya has very few female MPs, just over 7% them being women. For Uganda and Tanzania, the figures are 29.8% and 30.4%, respectively. More births are attended by skilled health personnel in Tanzania. And the rates of female genital mutilation are much higher in Kenya (32.2%) than in Uganda (0.6%) or Tanzania (14.6%).

Figures for communications, access to communications and media, water and sanitation vary somewhat here and there but there is still a surprising amount of similarity in these areas. All three countries have seen high population growth in the last thirty years and are predicted to continue growing. Demographic figures are also reasonably similar.

A notable exception is the urban population as a % of the total population, which stood at 20.7% in Kenya in 2005, 24.2% in Tanzania but only 12.6% in Uganda. Uganda also had a low urban population in 1975 and this is expected to continue. Urban population is thought to be a highly significant factor in the spread of HIV by some analysts. However, it is also argued that the HIV epidemic was unusual in Uganda, having started in rural areas and spread from there. In Kenya and Tanzania it was said to have started in urban areas.

In a nutshell, I think HIV spread readily in these countries because of poor health, education, social services, water and sanitation, governance, social cohesion and many other things. Many measures have been taken to reduce the spread of HIV, in the fields of health, education and other areas. However, unless the original development conditions that allowed HIV to spread are improved vastly, HIV will continue to spread.

The people of Kenya, Uganda and Tanzania may well need HIV education, but they are in far greater need of teachers and affordable, accessible schools. HIV health programmes are great, but only where there is an affordable, accessible health service. There is little point in educating people about sexual health and behaviour while ignoring reproductive health, sanitation, nutrition and other aspects of health.

As long as HIV is seen as a short term (or even medium term) crisis that will be resolved by crisis measures, it will continue to spread. Small gains may be made here and there, but without ensuring a healthy, well educated, secure population, HIV will never be conquered.

The conditions that allowed HIV to take hold and reach high levels in so many countries have been around for a long time and the HIV community seems to have allowed itself to be distracted by crises and crisis measures. It is the long term issues that need to be resolved, the same problems of poverty, exploitation and underdevelopment that have been around for as long as anyone can remember.

Absolutely Brutal Confident Dogma...

...engendering foolishly grotesque hype in blah blah blah.

I have mentioned before that, despite years of hype about HIV prevalence going down in Kenya and about how this was as a result of ABC (Abstain, Be faithful, use a Condom) campaigns, prevalence is actually rising.

It has been rising for three or four years. It went down earlier this decade, primarily, because of a very high death rate. The prevention campaigns only really started in the early years of the decade, when death rates were high. When death rates started to decline, prevalence started to go up again.

The increase in prevention money and campaign capacity was roughly concurrent with an increase in HIV transmission!

Uganda's HIV epidemic is older than Kenya's. The Ugandan government recognised the threat posed by HIV in the late 1980s and launched a multifaceted approach, one that was appropriate to a multifaceted epidemic. When prevention campaigns were at their strongest many people were dying. This reinforced the prevention message.

Foreign money started to flow into Uganda while prevalence was dropping. However, once death rates started to decline, prevention messages began to have less impact. At the same time, foreign money started to come with more explicit conditions.

Ugandan HIV organisations were encouraged (and eventually instructed) to emphasize the 'abstain' part of ABC at the expense of the other two facets. The emphasis on abstinence (or abstinence only until marriage) increased and spread to other countries because of further pressure from certain donors.

Many years ago, it was already clear that HIV was being transmitted by and to people who were not considered to be at high risk of contracting HIV. Married people were considered to be at low risk. This is odd, because it has long been clear that married people are being infected in large numbers. In some places, married people are at greater risk of being infected that highly sexually active, unmarried people.

You would think this would result in different campaigns evolving to support the ABC campaigns that became ubiquitous early this decade. However, as ample evidence showed that earlier hypotheses about transmission of HIV seemed less tenable, a dogmatic adherence to ABC and abstinence only campaigns became even more entrenched.

On the one hand, there are medical and field practitioners, showing that HIV is spreading among people previously thought to be at little risk of infection. On the other hand, there are political and other 'stakeholders' jumping on a moral bandwagon and referring to their approach as 'evidence based', whatever they meant by that.

HIV prevalence in Kenya will probably be higher next year than it was this year. But there have been warnings for several years that gains made in earlier campaigns in Uganda have also started to reverse. More people are admitting to having multiple partners than before, fewer people are reporting using condoms, even during high risk sex.

It would be surprising if HIV didn't start to show increases in transmission in Uganda similar to those that have occurred in Kenya. If it can happen in these two countries, there may be other countries where earlier declines in prevalence are reversed.

This is also a distinct possibility in countries where death rates are presently declining. Death rates decline around 10 years after peak incidence ( peak incidence being the time when the rate of transmission is highest). Even if death rates from HIV are not carefully recorded, HIV prevalence is under the spotlight in every African country. In any country where prevalence is declining, death rates are also high. It shouldn’t be too difficult to spot the countries most likely to experience an increase in HIV prevalence in the next few years.

At one time, people would ask if Uganda's success in fighting the HIV epidemic could be replicated in other countries. Perhaps this is no longer such a wise question. Perhaps, and this is purely speculative of course, but perhaps ABC doesn't really have that much effect.

Well, I think ABC has its place, but ABC on its own doesn't seem to do very much. Even less would abstinence only until marriage work, but we’ve known that for many years.

It has been demonstrated in many ways that HIV epidemics change over time and vary from place to place. At times, more men than women are infected, at times more women are infected. In the early years in Kenya, more men were infected. Later, far more women were infected. But the latest data shows that men are now being infected in higher numbers than before. At one time richer and better educated people were infected in higher numbers but this, too, is changing.

It may well be the case that HIV was, at one time, predominantly spread by high risk sex, involving sex with commercial sex workers, multiple concurrent partnerships and various other circumstances. But that would have been a long time ago. The HIV epidemics in Uganda, Kenya and many other countries have been 'generalised' for many years. This means that HIV is spreading among the general population, as opposed to specific groups, such as commercial sex workers, men who have sex with men, intravenous drug users, etc.

So, if the epidemic is different, why are the campaigns not different? The Ugandan First Lady has said that ABC campaigns will continue. Why? It is recognised that more infections occur in older people and inside marriages. What good will ABC campaigns do, even if they are supported by strategies that target high risk groups?

You can wag your finger at children and tell them to abstain and you may even be 'liberal' enough to tell them about what they are to abstain from. You may even shock the moral fibre of the nation by going on to tell them that they should be faithful to one partner, use condoms and other precautions and even send them off for VCT (voluntary testing and counselling). But can you wag your finger at adults and tell them what to do?

After all, many adults have sex in order to have children. It's something they have a right to and they are sure as hell not going to use a condom. Even if they want to avoid pregnancy they are likely to use a different form of contraception. Ok, you could, if you felt you had the moral authority, wag your finger at them and tell them to be faithful to one partner and they may not tell you where to direct your finger.

Really, you can have as many health campaigns as you want but they need to be based on genuine health issues, not moral crusades and political posturing. If the international community is worried about HIV transmission, they should take an interest in gender inequalities, economic inequalities (yes, poverty, I know how much they hate hearing that it exists), education, public health that is accessible to poor people, exploitation, water and sanitation and many other instances of people's human rights being compromised.

Of course people need to avoid high risk sex and there are ways of reducing risk. Everyone should avoid risky things, shouldn’t they? After all, they are risky. But there are so many more things that can be done, we needn't limit ourselves to the most difficult strategy of all, the vain hope that human beings will cease to engage in human behaviour.