The HIV industry has a very important junket coming up in Vienna and some of the industry's biggest donors are threatening to reduce funds. The World Bank's Global Fund and the US PEPFAR fund (President's Emergency Fund for Aids Relief), which represent a large proportion of global HIV funding, will be reduced over the next few years. Industry representatives are busy writing press releases, lobbying governments and doing everything in their power to fight for their right to party.
That sounds very cynical, but many people will die of Aids during the coming Vienna Aids Conference and during the many expensive junkets the industry treats itself to. The amount of money spent on such events must be astronomical and they are not usually even held in countries with high HIV prevalence. The same amount of money spent on HIV prevention or treatment could save a lot of lives. But HIV policy is mainly written by Westerners in expensive Western offices and when the policy is written, the writers celebrate in Western bars.
With all the hype around the much touted 'Treatment 2.0', it's hard to believe there will be much left to talk about at the conference. Ironically, there is a lot of talk about the use of mobile phones, laptops, wireless and various other technologies in the fields of HIV and global health in general. But you wouldn't think it to see all these people rushing to some expensive city, first class, expenses paid. Treatment 2.0 does involve a lot of technology, but not the sort that reduces costs or carbon emissions or anything like that.
According to PlusNews, one of the five priorities at the conference is 'universal' access to HIV drugs. This, despite what you might expect, involves putting 80% of people who need drugs on ART (antiretroviral therapy). The target was to achieve this by the end of 2010 but this will not be met by most countries. Even the target of putting everyone with a CD4 count (a measure of immune strength) of 200, rather than the WHO recommended 350, will not be reached.
Another technological approach is called 'treatment as prevention', the idea that people who are responding to HIV treatment will be less infectious and so will not be likely to transmit HIV. In ideal conditions, this works well. However, with so many countries still a long way from their targets, it is unlikely to have much impact in high HIV prevalence countries. In most of these countries, a substantial percentage of HIV positive people don't even know their status, so they will not be on ART. Treatment as prevention has been talked up for nearly two years now but no one has dared to admit that it is an ideal and will always remain an ideal. Even the jokers who came up with the 'no sex month' idea don't believe it.
Even nuttier than that is an approach called pre-exposure prophylaxis (PrEP). This involves putting those 'most at risk' of being infected with HIV on ART. If we had any idea who was most at risk we could have prevented a lot of infections by now. But we have been pretty unsuccessful in predicting who was most at risk in the past. And recent Modes of Transmission Surveys have shown that many of the people who are becoming infected are not in at risk groups. In fact, one of the characteristics of high HIV prevalence countries is that many of the people most likely to become infected are at low risk, according to official definitions! Figure that one out.
So there are a lot of technologies available but they are either not being used or they are not proving too effective in the field. It is difficult enough to persuade people to get tested for HIV once, let alone once a year for the rest of the time they are sexually active. Many who are HIV positive are either not taking the drugs, not taking the drugs properly or do not have access to the drugs or some other aspect of treatment (shocking, but no, you can't just hand out pills). Perhaps a lot of people are on treatment, but many of them will, eventually, develop resistance and need to go on to a far more expensive 'second line' drug. Technology is not simple, but conditions in developing countries are basic.
So what are the problems, if all this money has been spent for so long? Well countries need infrastructure, especially health infrastructures. They need education, especially health education. They need adequate levels of nutrition and food security. They need clean water and sanitation and many other goods that are considered to be human rights. You cannot roll out a high tech treatment or prevention program without countries having some level of development. It may seem possible to the HIV industry, donors or the public. But not only is it not possible, we've spent years demonstrating the impossibility.
In addition to these technical problems and the problems relating to our relative lack of understanding about exactly how HIV spreads, there is another problem, which is harder to characterize. This is the problem of the HIV industry's refusal to accept that we cannot explain high prevalence, generalized epidemics (where the majority of those infected are not members of high risk groups, such as intravenous drug users, men who have sex with men or sex workers) by almost exclusive reference to heterosexual sex. If you refuse to accept the racist, sexist explanations of HIV transmission in African countries being due to the fact that Africans have lots of unsafe sex, you will also refuse to accept that HIV prevention programs that target sexual behaviour, and nothing else, will reduce transmission to the extent that HIV will eventually be eradicated. I don't see what there is to celebrate.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
Showing posts with label abstinence month. Show all posts
Showing posts with label abstinence month. Show all posts
Friday, July 16, 2010
Wednesday, July 14, 2010
Two Point Zero Means We Haven't A Clue
A prominent UNAIDS spokesperson said "We haven't a clue what to do, really, we have never known. But we have noticed that putting '2.0' after anything will get you mentioned in all the press. And it's true, it works! We haven't had any ideas since we were established but we keep on repackaging tired old ideas that didn't work and the press tell the world what a great job we're all doing".
Sadly, a UNAIDS spokesperson didn't say that or anything else that could be verified. Such top-heavy, high spending bureaucrats with well padded buttocks are not known for making verifiable statements. But they do churn out a lot of photographs and colored diagrams. Their website, which was reasonably easy to find things on before, has succumbed to a late 1990s style splash page and underneath that, another splash page. Where they have put all their content has yet to become clear. Perhaps it's part of their 'treatment 2.0' effort. But some would say, quite cynically in my opinion, that this is no loss.
I was supposed to work for an organization that turned out to be siphoning off money from donors and using it for other purposes, nothing to do with development. But they had a real knack for finding people who would turn the right knobs when potential donors visited. If they were return donors, the same people could push all the right buttons to convince the donors that their money had been well spent and they would be wise to spend more. I think UNAIDS are similar. They have realised that one thing was missing from their attempts to break down in tears at every opportunity and beg for the massive amounts of money going to HIV treatment not to be cut.
They have realised that telling everyone that there are more people becoming newly infected with HIV than being put on treatment was not a good tactic, perhaps because it was too embarrassingly true. Even some of the more foolish people involved were able to think their way through the wet paper bag and see that this would mean the epidemic would just continue to expand. So now they are manufacturing figures to convince us that the childish 'prevention' programs they have wasted so much time on have worked, that you can just wave a magic wand and get people to do what you want and stop doing what you don't want.
On the surface, it looks like things have improved in Kenya a bit since 2000 and somewhat less so between 2003 and 2008. But the year 2000 was just after HIV prevalence peaked and started to drop. It dropped more quickly as death rates increased. Death rates probably peaked around 2003 or 2004 and HIV prevalence has changed little since then. It is claimed that hundreds of thousands of people are now on treatment so prevalence could be expected to have gone up as a result. But it doesn't seem to have done so yet. In fact, death rates are still quite high in Kenya. A few figures have improved between 2003 and 2008, people know the right answers to questions by now, but it is likely that HIV transmission is high enough to keep the epidemic going for some time to come.
If you buy the HIV industry's standard excuse (perhaps there's even an ISO number for it), that HIV is mostly caused by heterosexual sex, then you could easily find the figures seductive. More people now say they are having their first sexual experience later, they are having few partners, they use condoms more often, etc, etc. The behavioral paradigm holds that people (in African countries) have too much unsafe sex and all you have to do is persuade them to have less and HIV transmission will go down. The trend for 'safe' sex indicators has been going up since before HIV was ever heard of so, jumping on that bandwaggon, you could conclude that slight drops in HIV transmission have been a result of 'behavior change'.
If sexual behavior has changed significantly it is possible that some people are less likely to become infected with HIV. It all depends on things like whether they are male or female, urban dwelling or rural dwelling, of childbearing age, married or widowed and various other things. Females and urban dwellers are more likely to be infected. But far more people live in rural areas and out of the 1.5 million HIV positive Kenyans, about one million of them are rural dwellers. Also, the ratio of urban to rural infections is changing, with the percentage of rural infections rising. And while there are more women than men infected, that ratio is also changing. The percentage of men infected is catching up.
I have never seen any clear evidence that you can expect whole populations to say 'Oh, very well, then' when some foreign bureaucrats say 'Ok, you're having too much unsafe sex. Abstain, be faithful and use condoms.' People are more likely to say 'Butt out' or even 'What?'. But even if these 'prevention' efforts have had any effect, HIV is not just transmitted sexually. This is not news, it has been realized since HIV was first identified as the virus that causes Aids. It's just that, somehow, the HIV industry that subsequently developed didn't see non-sexual HIV transmission as worthy of their attention. Perhaps it's not 'treatment 2.0' enough.
So the articles about UNAIDS' non-new new approach are all over the place, bureaucrat-speak for 'We've really screwed up, but hey, that's our job, right?'. UNAIDS need to get clear about where HIV is coming from, who is transmitting it, in which areas and exactly how it is being transmitted. They have got by on 'modeled' figures for too long, figures that depend on too many unwarranted assumptions. Many people have been warning for years now that the behavioral paradigm is a piece of racist, sexist clap trap. They have written articles and books demonstrating how deceitful and misleading it is but UNAIDS and the entire HIV industry still takes this flat-earthist line.
The trouble is that when you set up a cabalistic peer-review system it eventually starts to poke up its own ass. All the 'experts' get together to scratch each other's backs, a sort of mutual delousing, and they agree that their articles are very worthy and must be published at once. Anyone from outside the cabal is ignored. There are millions of people being infected with HIV every year and after 25 years of research, all we can come up with is the same regurgitated nonsense in a new package? Why does UNAIDS still exist, after falling stillborn from the prolific UN? Is this is all they can come up with? People in developing countries, both HIV positive and HIV negative, deserve a lot better.
Sadly, a UNAIDS spokesperson didn't say that or anything else that could be verified. Such top-heavy, high spending bureaucrats with well padded buttocks are not known for making verifiable statements. But they do churn out a lot of photographs and colored diagrams. Their website, which was reasonably easy to find things on before, has succumbed to a late 1990s style splash page and underneath that, another splash page. Where they have put all their content has yet to become clear. Perhaps it's part of their 'treatment 2.0' effort. But some would say, quite cynically in my opinion, that this is no loss.
I was supposed to work for an organization that turned out to be siphoning off money from donors and using it for other purposes, nothing to do with development. But they had a real knack for finding people who would turn the right knobs when potential donors visited. If they were return donors, the same people could push all the right buttons to convince the donors that their money had been well spent and they would be wise to spend more. I think UNAIDS are similar. They have realised that one thing was missing from their attempts to break down in tears at every opportunity and beg for the massive amounts of money going to HIV treatment not to be cut.
They have realised that telling everyone that there are more people becoming newly infected with HIV than being put on treatment was not a good tactic, perhaps because it was too embarrassingly true. Even some of the more foolish people involved were able to think their way through the wet paper bag and see that this would mean the epidemic would just continue to expand. So now they are manufacturing figures to convince us that the childish 'prevention' programs they have wasted so much time on have worked, that you can just wave a magic wand and get people to do what you want and stop doing what you don't want.
On the surface, it looks like things have improved in Kenya a bit since 2000 and somewhat less so between 2003 and 2008. But the year 2000 was just after HIV prevalence peaked and started to drop. It dropped more quickly as death rates increased. Death rates probably peaked around 2003 or 2004 and HIV prevalence has changed little since then. It is claimed that hundreds of thousands of people are now on treatment so prevalence could be expected to have gone up as a result. But it doesn't seem to have done so yet. In fact, death rates are still quite high in Kenya. A few figures have improved between 2003 and 2008, people know the right answers to questions by now, but it is likely that HIV transmission is high enough to keep the epidemic going for some time to come.
If you buy the HIV industry's standard excuse (perhaps there's even an ISO number for it), that HIV is mostly caused by heterosexual sex, then you could easily find the figures seductive. More people now say they are having their first sexual experience later, they are having few partners, they use condoms more often, etc, etc. The behavioral paradigm holds that people (in African countries) have too much unsafe sex and all you have to do is persuade them to have less and HIV transmission will go down. The trend for 'safe' sex indicators has been going up since before HIV was ever heard of so, jumping on that bandwaggon, you could conclude that slight drops in HIV transmission have been a result of 'behavior change'.
If sexual behavior has changed significantly it is possible that some people are less likely to become infected with HIV. It all depends on things like whether they are male or female, urban dwelling or rural dwelling, of childbearing age, married or widowed and various other things. Females and urban dwellers are more likely to be infected. But far more people live in rural areas and out of the 1.5 million HIV positive Kenyans, about one million of them are rural dwellers. Also, the ratio of urban to rural infections is changing, with the percentage of rural infections rising. And while there are more women than men infected, that ratio is also changing. The percentage of men infected is catching up.
I have never seen any clear evidence that you can expect whole populations to say 'Oh, very well, then' when some foreign bureaucrats say 'Ok, you're having too much unsafe sex. Abstain, be faithful and use condoms.' People are more likely to say 'Butt out' or even 'What?'. But even if these 'prevention' efforts have had any effect, HIV is not just transmitted sexually. This is not news, it has been realized since HIV was first identified as the virus that causes Aids. It's just that, somehow, the HIV industry that subsequently developed didn't see non-sexual HIV transmission as worthy of their attention. Perhaps it's not 'treatment 2.0' enough.
So the articles about UNAIDS' non-new new approach are all over the place, bureaucrat-speak for 'We've really screwed up, but hey, that's our job, right?'. UNAIDS need to get clear about where HIV is coming from, who is transmitting it, in which areas and exactly how it is being transmitted. They have got by on 'modeled' figures for too long, figures that depend on too many unwarranted assumptions. Many people have been warning for years now that the behavioral paradigm is a piece of racist, sexist clap trap. They have written articles and books demonstrating how deceitful and misleading it is but UNAIDS and the entire HIV industry still takes this flat-earthist line.
The trouble is that when you set up a cabalistic peer-review system it eventually starts to poke up its own ass. All the 'experts' get together to scratch each other's backs, a sort of mutual delousing, and they agree that their articles are very worthy and must be published at once. Anyone from outside the cabal is ignored. There are millions of people being infected with HIV every year and after 25 years of research, all we can come up with is the same regurgitated nonsense in a new package? Why does UNAIDS still exist, after falling stillborn from the prolific UN? Is this is all they can come up with? People in developing countries, both HIV positive and HIV negative, deserve a lot better.
Sunday, July 4, 2010
You've Been Bad: No Sex for a Month
One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.
This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.
So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.
There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.
Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.
The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.
More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.
If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?
Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.
Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.
The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.
Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.
The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.
This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.
So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.
There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.
Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.
The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.
More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.
If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?
Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.
Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.
The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.
Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.
The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.
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