Paid to Fail: the Politics of HIV Research

I recently commented on a much hyped but relatively vacuous paper by Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson, entitled 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?'

But there was one item in the paper I didn't comment on that has stuck in my mind since. They write: "Many men in focus groups and interviews reported that having less disposable income has increasingly led to reduced ability to purchase sex or maintain multiple sexual relationships".

The sentence sounds reasonable enough if you accept the overall conclusion of the paper, that changes in sexual behavior driven by fear of HIV infection resulted in massive reductions in HIV transmission. But the data used by the paper only shows minor changes in sexual behavior. In truth, correlations between sexual behavior and HIV transmission are as unconvincing as they always have been, in Zimbabwe and elsewhere.

But even thinking about this sentence from an economic point of view and the little we know about commercial sex, does having less disposable income necessarily result in a reduced likelihood of purchasing sex? I think the real worry when money becomes scarce is that those who depend on providing sexual services for money have to settle for less money or provide more and/or riskier services.

Of course, such hypotheses need to be tested and many HIV researchers are reluctant to carry out rigorous research into sexual behavior. If sex turned out to be less relevant to HIV it's likely that funding would dry up. And if HIV prevention turned out to be a matter of providing decent health care, those currently selling drugs would also quickly lose interest.

There must be a lot of money in providing safe health care but it doesn't seem to attract the donors. But then, it's important to sell HIV drugs to developing countries because that's where the bulk of the market is. The same can't be said for other health care goods and services; not yet, anyhow.

Another problem with the idea that commercial sex becomes less common when money is scarce is that you'd think the trend for wealthier people to be infected in greater numbers than poorer people would reverse. This trend has reversed in some countries, but not noticeably as a result of economic changes.

The authors of the paper in question put a lot of credence in focus group discussions and that seems unwise. But it's their analysis of those findings that seem most disingenuous. The analysis appears to be independent of the data on sexual behavior, probably because the data is the same in high prevalence countries as it is in low prevalence countries. It's almost as if they are saying "here's the data, it contradicts our conclusions but everyone knows our conclusions are true anyway".

Because this paper doesn't even give a convincing pretense of having any substance, I'm still wondering what is behind it. The authors are very well established so the only reason I can think of that they would put their names to such rubbish is that they know no one really cares how they come to their conclusion as long as they come to the approved conclusion. But it seems like an expensive and circuitous way of failing to reduce HIV transmission.

Researchers Have No Opinion On Nosocomial HIV Infections in Zimbabwe

Non-sexual HIV transmission, when it's even discussed by the HIV orthodoxy, is usually dismissed with little argument and no evidence. What is most extraordinary is that one could hypothesize that both sexual and non-sexual transmission contribute to most epidemics and then try to work out the relative contribution of each. But they don't tend to do that.

Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson toe the party line in their recent paper 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?' They barely even mention non-sexual transmission and completely dismiss its significance.

But they do come to a very media friendly and quotable 'conclusion', that "fear of contracting the virus [is] the primary motivation for changes in sexual behavior". Journalists have pounced on this 'finding' and will continue spreading it for some time. Perhaps these researchers have recognized the value of media friendliness and found it to be more congenial than credible, enlightening research that could turn around the HIV pandemic.

Despite constant boasts about the number of people on antiretroviral treatment and the idea that you can contain an epidemic by throwing lots of drugs at it (which happens to be the current global treatment policy), these researchers even mention the very real possibility of drug resistance making mass treatment campaigns less sustainable than they currently are. They are in good company; Bill Gates recently said more less the same thing.

But what was their quotable conclusion based on? Well, they did a bit of mathematical modelling and read a few papers written by like-minded people (actually, the bibliography overlaps considerably with the list of authors), but they also give a lot of credence to a bunch of 'stakeholders', who certainly seemed to do a fair amount of agreeing with each other. Perhaps they see this as quantitative, their credence, the stakeholders' agreement, etc.

It's odd, when people say they have never had sex, never had unprotected sex or never had sex with anyone other than their partner (who is often HVI negative), they are unlikely to be believed, especially if they are African. But if they are like-minded people holed up in a hotel, their responses are treated at face value.

"[T]he unanimous conclusion from the stakeholders meeting held to assess, triangulate, and interpret the evidence assembled in the review was that a reduction in multiple sexual partnerships was the most likely proximate cause for the recent decline in HIV risk." What a surprise.

It goes on: "In assessing the underlying factors for the national prevalence decline, high AIDS mortality appears to have been the dominant factor for stimulating behavior change." Yet, high AIDS mortality has been a phenomenon in many countries that have had very high HIV prevalence. When lots of people become infected, lots of them die, widespread treatment regimes notwithstanding.

Similar claims used to be made about Uganda, though these researchers are also keeping Uganda at arm's length. Well, it's almost certainly true that some people were devastated by what they saw around them when huge numbers of people were dying terrible deaths. That would have some impact on anyone.

But the idea that it would be almost entirely responsible for levels of behavior change that resulted in a massive drop in rates of new infections in a short space of time in Zimbabwe, but nowhere else, is not credible. Nor is it even necessary to make such a foolish claim.

The economic decline experienced in Zimbabwe in the late 90s and early 2000s, we are told, played a considerable secondary role in amplifying patterns of behavior change. No doubt it did. But economic decline could also have resulted in fewer visits to the country's deteriorating health facilities, which would have reduced the number of nosocomial infections (infections resulting from medical treatment).

And what levels of behavior change occurred? From the figures cited, age of sexual debut and condom use barely changed. And multiple partnership indicators improved a bit, but these were never common enough to explain the almost umprecedented rates of transmission once found in the country. Most of these indicators wouldn't even look out of place in rich countries.

Interestingly, the researchers mention "the Zimbabwean government's early adoption of a home-based care policy [which] may inadvertently have accelerated the process of behavior change. It has been hypothesized that, when people die at home, this direct confrontation with AIDS mortality is more likely to result in a tangible fear of death among family and friends than when patients are primarily cared for in clinical facilities, such as in Botswana"

I'd interpret the effect of this policy rather differently. It could also have taken a lot of HIV positive people out of a health system that was not able to provide people with safe healthcare.

The authors conclude that significant changes in behavior are unlikely to have resulted from increasing levels of mortality alone. They also suggest that prevention programs provided people with information about the link between risky sexual behavior and HIV transmission. And they are probably right, to an extent. But why were these programs so successful in Zimbabwe when they failed so miserably elsewhere? The authors bluster on, unconvincingly.

Indeed, they don't even seem that convinced themselves. They can't really put their finger on anything much so they talk about "cumulative exposure" to prevention messages, as if that wouldn't have happened elsewhere. Similar claims have long been made to "explain" what happened in Uganda. After all, there must be some explanation, and if it has to be about sex this one is as good as any other.

I can understand a whole group of stakeholders churning out answers that would satisfy even a UNAIDS employee about the drivers of HIV. I have met few people who wouldn't say similar things. But I don't believe the authors could look on this this paper as a publishable piece of research. If they are all happy with it, then I am disgusted. Their own research screams for investigation of non-sexual transmission levels, but they carry on regardless.

Global HIV Policy: Blame, Stigma and Finger-Wagging

With HIV/AIDS, it's always been easier to blame individuals for their reckless behavior than to examine the conditions people live in and figure out which of these conditions may explain why HIV prevalence varies from a fraction of a percent in some populations to 25% in others and even 40% in some demographic groups.

The idea that whole populations have hundreds of times less sexual experience than other groups is not credible, especially where birth rates may be very high in some countries with low HIV prevalence. India is an example of a country with high birth rates and HIV prevalence lower than 1%. There is no reason to think that Indians in general shy away from sex.

While prevalence is a lot lower than 1% in most demographic groups in India, it is 30-40% in some demographic groups in several African countries. In fact, prevalence among Indian sex workers is only 7%, which is about the same prevalence as found in Kenya, Tanzania and Uganda. Yet sex workers in India face terrible risks, far worse than most sexually active people in African countries.

That HIV prevalence is not correlated with individual sexual behavior is nothing new. But some researchers have shown that HIV prevalence is correlated with malaria prevalence, something that is clearly not just a matter of individual behavior. Whether it makes HIV positive people more likely to transmit the virus, HIV negative people more likely to be infected or both is not clear. I have only seen the abstract. But it is one more nail in the coffin for the 'individual responsibility' theory of HIV prevention.

People in high malaria prevalence areas are more than twice as likely to be HIV positive as those in low prevalence areas. Some people have been calling for research into cofactors in HIV transmission for years but such research is still relatively uncommon. But similar research was recently carried out on schistosomiasis (bilharzia) as a co-factor and it was found to be associated with higher HIV prevalence. Tuberculosis also makes people more likely to transmit and to be infected with HIV.

Further loosening the connection between HIV and individual sexual behavior, it has also been shown that "a number of biological factors are critical in determining whether an unprotected sexual exposure to HIV results in productive infection". Mentioned are "viral factors, host genetics, and the impact of co-infections and host immunology" but again, I only have access to the abstract.

These researchers even have the effrontery to claim that "HIV sexual transmission is very inefficient". That's true, but it's not something that the sex obsessed HIV industry likes to dwell on. Global HIV prevention policies are based on blame, stigma, finger-pointing and finger-wagging, not research. But these upstarts go on to mention destigmatizing the issue, leading to new and more effective strategies for prevention. Whatever next?


Another batch of researchers conclude that because new HIV infections among discordant couples (where only one partner is infected) are twice as likely to occur among those trying to have a baby, this must be a result of higher levels of 'risky' sexual behavior. Having sex with your partner is not risky, or shouldn't be. But having a baby seems to be, especially for the female partner. Perhaps the researchers would like to assess the non-sexual risks that pregnant women face, such as unsafe health care.

The researchers may well be right and their research is certainly very interesting. But any research into HIV transmission among discordant couples, especially where pregnancy is involved, is incomplete without some clarification about how the women are being infected. Sure, they must be having sex if they are trying to have children, but this does not mean that transmission is always sexual.

The 'concurrency' card is still frequently played by those in the know (about how to receive copious amounts of funding) but it is still unsupported by clear evidence that it is common or that it really does explain high rates of HIV transmission. This research from Kenya pours cold water on the concurrency theory, finding that only 3.5% of females and 4% of males were engaged in concurrent partnerships in the previous six months.

The authors claim their findings suggest that: "concurrency expands individuals' sexual networks and bridges additional networks involving partners' other sexual partners". Perhaps, but with such low rates of concurrence, it's unlikely to do so to any great extent.

We need credible explanations for high rates of HIV transmission and viable prevention interventions, not the institutional racism and sexism that we have come to expect from UNAIDS and their ilk. UNAIDS have spent long enough showing that they are not capable of acting on research, especially research that exposes their prejudice for what it is. It's time for them to stand aside and let an unbiased institution take over.

Increase Testing, Find Out What is Really Driving HIV Epidemic in South Africa

There is a debate in South Africa about whether schoolchildren from 13 up should be tested for HIV. Some are opposed to testing, apparently claiming that children "may not be psychologically prepared to deal with a positive result or the stigma likely to follow". But the point of pre- and post-test counselling is to psychologically prepare people for getting the test and finding out the result.

This may be more difficult in the case of younger children. But that doesn't make it any less necessary. The alternative is to wait until symptoms appear, by which time treatment will be more difficult and the risk of serious illness and even death are increased. If found to be HIV positive, people can be monitored and treated as and when treatment is required.

South African health services may not have the capacity to treat all those who are in need of treatment. But they need to test as many people as possible to assess what exactly their needs are. Even if they can't give everyone the level of treatment they require, those who are not tested won't get any treatment at all.

The fact that, as one teachers' union representative points out, even parents are afraid to be tested, is not a reason for not trying to increase the numbers of people being tested. People have been filled with notions about HIV in Africa being transmitted almost exclusively by promiscuous behavior, which means that HIV is still highly stigmatized, even after thirty years of research showing that it is not solely spread sexually and it is not primarily a matter of individual responsibility.

But teachers, teachers' unions and others should be aiming to reduce stigma, not accepting it as inevitable. They may be correct in claiming that the government is trying to make up the numbers for their exaggerated claims about how many people they were going to test in a short space of time. Certainly, testing large numbers of children, who may be seen as easy targets, is a very cynical way of achieving projected figures.

However, countries with high HIV prevalence need to test more people, especially younger people. There are three reasons, the first being that people have better health outcomes if the disease is caught early.

The second is that testing early should help to work out how people are being infected. For example, some will have been infected by their mother, some will be sexually active and some will not fall into either of these groups. People who are neither sexually active nor infected since birth will need to be investigated carefully to find out exactly how they are being infected.

Nosocomial infection is very likely to be responsible in many instances. Failing to identify such sources of new infection and failing to do anything about them will result in continuing high rates of HIV transmission in South Africa and other countries where similar failures occur.

The third reason for testing as many people as possible is that HIV prevalence among young people is a useful proxy for HIV incidence, the yearly rate of new infections. Incidence is very hard to measure but without such measurements, it is difficult to predict how the epidemic is going, whether it is increasing or reducing.

Being able to treat infected people is only one good reason to test as many as possible. Finding out what is driving the epidemic is, arguably, even more important. Far more people are at risk of becoming infected than are already infected. One of the aims of HIV policy in South Africa needs to be to prevent new HIV infections, not just to passively identify those already infected so they can be treated accordingly.

Young people, especially young girls, are those most at risk of being infected with HIV. That harsh reality is a lot better than the reality of being HIV positive. If people are still afraid to be tested then the South African Government needs to challenge global HIV policy, which denies that a significant amount of HIV transmission could be non-sexual. If South Africa, with the largest HIV positive population in the world, is not prepared to stand up to this erroneous claim, who will be?

Unfortunately, a lot of young people will be identified as HIV positive even though they have never had sex. And they will not all have been infected by their mother, who may not herself be infected. Not all HIV positive young South Africans are being infected sexually so it needs to be made clear how they are being infected. Only then can the South African epidemic be successfully tackled. The less involvement from UNAIDS and the HIV industry, the better.

Sexual Behavior: Myth Supports the Assumption, Evidence Does Not

IRIN has a recent article entitled "Fidelity campaigns could take years to see results". This is not news. Campaigns advocating abstinence, limiting sex to one partner and using condoms have been around for years and it is well known that they take years to show any results. It is also well known that they don't have very much effect on HIV prevalence.

Despite this, much of the money spent on HIV prevention, a very small amount compared to that spent on treatment and care, is used for fidelity campaigns of one kind or another. They usually result people in being able to trot out the right answers to questions, which keeps the market researchers happy. And, in the end, these campaigns are a good way of spending lots of money.

Various institutions that have bought into these empty campaigns are very well funded and can afford good marketing. They are hardly going to produce reports showing that their campaigns were pretty pointless. Rather, they will put a gloss on everything so that they can continue to receive funding. That's often what the funders want, too.

Institutions such as PSI, that were set up to interfere in the sexual and reproductive health of people in developing countries, can be expected to spend their enormous budgets on their traditional interests of population control (or 'eugenics', as it used to be called). But they really don't need to react with such surprise when their campaigns continue to fail to make much impression on HIV transmission rates.

Whatever the claims of PSI and similar institutions, fidelity and other behavior change approaches to HIV prevention are constantly referred to as 'evidence-based', as if that vouched for their effectiveness. But the notion that "over 90% of adult HIV infections in sub-Saharan Africa are acquired through sexual contact" is an article of faith in the HIV industry, even though the dubious claim dates back almost 20 years.

An article published in BioMed Central, by Marshall Munjoma, et al, simply assumes the truth of this 'behavioral paradigm', assumes that Africans lead incredibly active sex lives, care little about their health, the health of their children or the health of their partners, and takes things from there. And yet, the article strongly suggests that not all HIV is transmitted sexually.

These researchers start by pointing out that HIV incidence, the yearly rate of new infections, peaked in the late 1980s and declined thereafter. They don't explain the initial spread of HIV, the peak in incidence, nor its subsequent decline. And they certainly don't relate these phenomena to sexual behavior.

Yet, if the sexual behavior theory of HIV transmission is true, the major changes in behavior must have begun in the 1980s. By the end of the 1990s, most people who were infected in the 80s would have died and those infected in the 90s would have continuted to die into the 2000s. Once incidence peaked and declined, little further behavior change is required to explain what happened since the late 1990s.

Not only do the researchers fail to explain the sexual behavior changes that must have begun in the 80s and continued through the 90s but they attribute the rapid declines in prevalence in the late 1990s and early 2000s to changes in sexual behavior! The decline in prevalence is due to high death rates. High death rates continue to reduce prevalence in Zimbabwe and new infections also continue, just at far lower rates than in the 1980s.

The researchers note that new infections among women attending ante-natal clinics women are very high over a 6 year period in the 2000s. But many of these infections probably occurred during the women's third trimester or not long after giving birth. Why is it assumed that they must have been infected sexually? Some of these women were probably not having sex very much at these times. Were their partners tested?

The study also found that half those infected were 20 years or younger and nearly 100% of married women reported having sex with their spouses only. The researchers seem content to ignore the possibility of non-sexual transmission in at least some of the people they spent so long tracking. What is the point of research that ignores such vital clues as to how HIV may be transmitted?

To tie in with the IRIN article and the blind faith in behavior change interventions, the authors conclude that the decline in prevalence is due to behavior change, even though 90% of the study participants, both those who seroconverted and those who didn't, do not believe that abstinence protects against HIV. If people don't believe abstinence will protect them, why would they abstain?

African Heterosexual Females Branded By Global HIV Policy

The murdered Ugandan gay activist, David Kato, was one of the victims of a piece of persecution by a tabloid newspaper, Rolling Stone. Rolling Stone published the names and photographs of people they believed to be gay. By the time a judge got around stopping publication the damage had been done.

I can't prove that David Kato was murdered because he had been exposed, I can't even prove he was murdered. But his death illustrates the sort of thing that can happen in a country where persecution of certain people is not considered important enough by the state to give them the protection they need.

The sort of hate and prejudice that lies behind the murder of David Kato exists everywhere, but some countries have laws to protect people from its worst excesses. Most gays can probably remain anomalous, or hope to. But they will all live in fear of discovery. If discovered, they could become victims of police violence, mob violence, persecution, extortion and the like.

But gays are just one group that suffers the consequences of hatred and prejudice. In some African countries, women are equally stigmatized. They can also be victims of violence and suffer injury, persecution and even death because they are a member of a stigmatized group.

Not all women are stigmatized to the same extent. But most victims of sexual and non-sexual violence are women. And the law in many countries gives them little protection, especially if the perpetrator of the violence is their husband or another family member.

In most countries, women are more likely to be poorer than men, live in worse conditions, play the biggest part in raising children, have lower levels of education, have less access to health and other social services and the list goes on. This is a result of prejudice, but of course, this is not the same kind of prejudice experienced by gays.

Women start to experience the kind of prejudice experienced by gays when high HIV prevalence is added into the picture. Fingers are pointed at sex workers and other groups. But in countries where HIV prevalence is highest among ordinary married women who only have one sexual partner, Uganda being a case in point, all women are branded as promiscuous.

Men are also branded as promiscuous, but HIV rates are far lower among men. Even people who just read what appears in the mainstream press suspect they are being lied to when they are told that it's men who go around spreading HIV and yet far more women are infected.

I often ask people for their opinion on how HIV is spread and if they think it's odd that in some places, HIV positive women can outnumber HIV positive men by 5 to one. They sometimes come up with the ludicrous suggestion that there is a small number of men who are responsible for infecting huge numbers of women. They must be very busy and such a group has never been identified.

Not for want of trying. Fingers have been pointed at 'mobile' people, either internal or external migrants, long distance drivers, armies and many other groups. But in the end, the majority of people being infected with HIV are ordinary people with ordinary sex lives. What UNAIDS refers to as 'low-risk' sex is, in fact, very high risk. I think of this as the UNAIDS paradox.

There is no paradox if you bear in mind that not all HIV is transmitted sexually, that some, perhaps a lot, is transmitted through unsafe healthcare and cosmetic practices. Most people are aware of these phenomena but there is a great reluctance to investigate. People prefer to say 'well, you're right, but I still think it's mostly sexually transmitted', or worse.

So I am not arguing that people who are HIV positive, whether they are gay, involved in sex work, injecting illegal drugs or anything else, shouldn't be stigmatized because stigmatizing people is wrong. It is wrong. But HIV positive people shouldn't be stigmatized because we don't know how they became infected. And even if they were infected sexually, that doesn't mean they have done anything wrong.

Anti-gay and other prejudices are not new and they are proving hard to reduce. But Africa suffers from an anti-African prejudice, based on the UNAIDS lie that 90% or more HIV in African countries is transmitted sexually. Effectively, heterosexuals and those who engage in heterosexual sex are the victims of prejudice and stigma.

If anti-gay stigma reduces the number of gay people who take precautions against infection with HIV, anti-African, anti-woman and anti-heterosexual stigma does the same. Few people want to be tested for HIV unless they have to because merely raising the possibility that you are infected invites suspicion, finger-pointing, ostracization, persecution and physical violence.

Like HIV itself, stigma doesn't just arise from 'somewhere else', from foreigners, migrants, Africans, women, right wingers, Muslims, or whatever. Stigma, HIV related stigma in particular, arises from the way society as a whole has come to view sex, all sex. The 'proof' that sex is bad is the existence of a HIV pandemic. But the evidence that the pandemic was driven by sex? Alas, there is none. That's why it's called prejudice.

Concurrency: the Favorite Plaything of the Sex-Obsessed HIV Industry

For a relatively short time, the notion of concurrency became the favorite plaything of the sex-obsessed HIV industry. They hypothesized, not just Africans with rampant and uncontrollable sexual urges, but Africans with sexual partnerships that overlapped with each other.

If serial monogamy refers to the practice of finishing one relationship before going on to another, concurrency increases the chances of infecting more than one person. Given normal probability of transmission through penile-vaginal sex, those subscribing to the purely sexual theory of HIV transmission need all the help they can get.

But some have speculated about another aspect of rapid transmission, which has been well demonstrated, but never clearly tied to concurrency. The probability of transmitting HIV is highest during the first three months of infection and during the last 9 months or one year. During the latent phase, which can last 8 years or so, probability of transmission is especially low.

So, if someone acquires HIV, they are highly infectious during the first few months. Sex-only HIV transmission theorists need that person to infect several people during that short period to explain exceptionally high prevalence found in some countries. Concurrency may help explain high prevalence, but it doesn't completely explain it.

More embarrassing for these adherents of the 'behavioral paradigm', the belief that sexual behavior accounts for the bulk of infections, is that concurrency doesn't appear to be very common in many countries, even countries with high HIV prevalence.

People like Jeffrey Eaton, Timothy Hallett and Geoffrey Garnett have gone to great lengths to push concurrency, and the behavioral paradigm in general, but they have even discovered that it just can't be pushed that far. They try to model the effects of relatively low levels of concurrency that also take into account the stage of HIV infection. They even use ridiculously high estimates of transmission rates.

But they are forced to conclude that "this model produces HIV epidemics that grow more slowly than those observed in southern Africa, suggesting that factors not included here—in particular, small groups with greater number of sexual partners and cofactors that increase HIV transmission—also contribute to accelerating the spread of HIV".

This is a completely deflating argument, showing that some level of concurrency has some influence on rates of transmission, possibly. The level of influence, like rates of concurrency, is not estimated. Perhaps it's not even possible to estimate it.

Another study suggests that many people in high prevalence countries don't have very many partners (Table 2). The percentage of people who had more than one partner in the last year before the study ranged from 6% in Malawi to 25% in Lesotho. Fair enough, Lesotho is a high HIV prevalence country, but so is Swaziland, where only 10% had more than one partner.

And having more than one partner is not the same as concurrency. Eaton et al find that "increasing from 10 to 11% of individuals having concurrent partnerships increased the mean endemic HIV prevalence from 3 to 7%." We can't assume concurrency is higher in high prevalence countries without arguing in a circle (though mathematical modeling is probably no stranger to circular arguments). What the researchers say may be true, but we don't know what truth it expresses.

Even if concurrency plays a role and that role can be quantified, how do we then explain the rise, peak and decline in HIV rates in most sub-Saharan African countries before most prevention programs started and long before the notion of concurrency became the popular plaything it is today?

Eaton et al conclude that "primary infection in the context of concurrent sexual partnerships may be the factor that has enabled HIV to spread through general populations to such high levels." They are entitled to conclude that it may be a factor, not the factor. And that doesn't really get us much further.

But there isn't much further to go when your only contribution to HIV transmission theory is that it is a sexually transmitted infection. It is, but to what extent? It is also transmitted from mother to child, by injecting drug use, through unsterile health care practices and even unsafe cosmetic practices.

If Eaton et al want a model that grows like some of the epidemics found in some sub-Saharan African countries, they need to factor in non-sexual transmission. Otherwise they will continue to be in the dark and to leave everyone else in the dark. And the useless HIV prevention strategies that have dominated the field for so many years will continue to fail.

The UNAIDS Paradox: Low Risk Sex Appears to be Risky in Africa

Aidsmap.com has an article about a study carried out in Uganda which shows that there is little evidence of an increase in risky sex since the widespread rollout of antiretroviral drugs (ARV). Many people have been worried that the (relatively) easy availability of such drugs could give rise to both HIV positive and negative people disregarding principles of 'safe' sex.

It is not just in Uganda and other African countries where there are worries that such increases in risky behavior could follow ARV rollout. Wealthy countries have shown that increases in risky behavior are a reality and that this could easily wipe out some of the gains that have been made over the years. People are just not as frightened of HIV as they used to be.

But in the case of Uganda, the study gives the impression that risky sexual behavior is not such a big thing there. More surprisingly, it sounds as if it never was. After starting treatment, some people engaged in higher levels of risky behavior but later this trend reduced. In the end, they reverted to pre-treatment levels.

Well, if pre-treatment levels of risky behavior are not worrying in HIV positive people, they must be even less worrying in HIV negative people. There have been other studies like this one, also giving the impression that levels of unsafe sexual behavior are fairly low. Not that anyone has produced data showing what could count as normal and what could count as high when it comes to sexual behavior.

Not only that, even those who talk about high levels of unsafe sex don't really show that levels really are higher than elsewhere. Nor do they appear to have any reliable data to show that higl levels of unsafe sex occur more in African countries, nor in countries and regions where HIV prevalence is high.

It can be odd listening to people talking about HIV because they appear to consider the issue important, but also, in a sense, unreal. For a start, they always talk about sex, especially illicit and unsafe sex. It's as if some sex, most sex, if they are to be believed, falls into that category, while a small amount does not.

But as to what constitutes a lot of sex, no one I have asked can really say. It has been suggested that people who are HIV positive have at least one different partner a week, perhaps more, but these are just assumptions. As to why it is even assumed that some people have so many partners, and I'm not doubting that some people do, it often seems to relate to the perceived number of people who go to bars and drink alcohol.

But the Ugandan study does confirm one thing; levels of unsafe sexual behavior are not, in general, high. They probably never were. There has never been evidence of a glorious time before the HIV epidemic, when hardly anyone engaged in unsafe sex. Nor for a time when levels of unsafe sex rocketed, allowing HIV to spread rapidly. Nor for a time when all this subsided and HIV transmission rates began to decline to present levels.

Other research leads to similar conclusions. The five yearly Demographic and Health Surveys show that those who engage in risky sex are often less likely to be infected with HIV than those who don't. Trials such as the CAPRISA microbicide trial showed that the majority of people had a few sexual experiences a month and most of them only had one partner.

The Uganda study also found that use of condoms among HIV positive people increased after they started treatment. This may well be, as claimed, due to 'incraesed counselling intensity'. But condom use wasn't very high to start off with. As a minimum, you would expect people being counselled and on treatment to take some extra precautions.

However, a substantial proportion of those most likely to transmit the virus still don't wear condoms. It's hard to know if the 'intensive counselling' really has all that much effect. And when you look at sexual behavior among HIV negative people, the many years of HIV prevention interventions look even less impressive.

But the article is 100% about sex. There is never a hint that transmission may occur through any other route. Non-sexual routes to HIV infection may well have been talked about earlier on in the epidemic and, in the case of Uganda, steps may have been taken to reduce their impact. But now sex has completely taken over.

The fact that the HIV industry is attributing declines in transmission to HIV prevention programs that only started a long time after the declines suggests that they don't know why transmission declined. They don't seem to know how to reduce transmission and they don't even seem too bothered by that.

If we still don't know why HIV spread and subsequently declined, after thirty years of research, then nor do we know what to do if transmission rates begin to increase again. Don't people find that frightening? UNAIDS' claim that Uganda's epidemic is driven by low risk sex is not credible.

Unethical Tuskegee Style Trial Being Re-run in African Countries

The issue of male circumcision has cropped up on this blog because of claims that it can reduce HIV infection in men. It is not claimed that it reduces infection in women, though there is often that implication. In fact, circumcised men may be more likely to transmit HIV to women.

However, here's what one of the 'experts' and flag-waving proponents of mass male circumcision, Dr Maria Wawer, has to say: "Circumcision removes the foreskin of the penis, which is rich in immune system cells targeted by HIV and perhaps other viruses. Taking off the foreskin likely makes the penis less likely (sic) to carry a range of microbes."

The lack of certainty that I express using the word 'likely' stems from the fact that I am not a scientist, nor am I collecting and analyzing data directly. There is conflicting evidence, to a large extent because much of the research has concentrated on demonstrating the effectiveness of male circumcision, rather than considering if it is really going to reduce HIV transmission.

But 250,000 Kenyan adult men have been circumcised because Dr Wawer and her colleagues think the operation is 'likely' to be effective. They have no idea why it might be effective, if it really is. Worse still, the best that can be hoped for in terms of transmittion reduction is really nothing to get excited about.

The claimed 60% reduction in HIV transmission was achieved in groups of people who were 'counseled' (indoctrinated) at length on 'safe' sex, urged to use condoms and monitored regularly for a relatively short time. What was really established was that if people, circumcised or uncircumcised, used condoms consistently every time they have sex, HIV transmission issignificantly reduced.

Far from publishing critical analyses of these rather poor results, much has been made about the protective benefits of circumcision against other sexually transmitted infections, such as human papilloma virus (HPV), which can cause cervical and other cancers. Yet again, the figures are not that impressive. Their '28% lower rates of transmission' in field trials could be far lower in practice.

But supposing the protection was real and male circumcision does give some protection against some STIs, or even just one? Would this mean that those who seem so vehemently opposed to mass male circumcision, and that includes me, need to backtrack?

I'm not opposed to proven interventions that reduce HIV transmission, such as prevention of mother to child transmission (PMTCT). What I am opposed to is half-baked interventions that may appear to give some small benefit but may also be doing a lot of harm.

The trial Wawer is involved in like the Tuskegee syphilis trial, where the ultimate outcomes for those taking part is not the concern of those doing the research. They are not worried whether participants become infected with HIV or anything else, they just want to know the circumstances so they can develop interventions for Western countries.

Why circumcision is still of so much interest is not clear, it of no use among men who have sex with men and unless people use condoms during heterosexual sex, it is of no use to them either. It's big in the US and must make a lot of money for the healthcare industry.

But it doesn't appear to protect people much in the US, either. HIV prevalence in the US, especially in some cities, is far higher than in European countries, where circumcision is not very common. Other STIs are also more common in the US, sometimes 10 or 20 times higher than in many European countries.

In African and other developing countries, though, the risks associated with circumcision are far higher than they are in Western countries, with their good health services and fairly numerous health personnel. Countries like Tanzania, Kenya and Uganda have deplorable health services, chronic shortages of skilled personnel, inadequate supplies of equipment and a serious lack of safety and infection control processes.

Going for an operation, even getting a tooth pulled or receiving an injection in many African and other developing countries is a serious risk. The Tuskegee syphilis style trials mentioned above don't bother checking what non-sexual risks people face in their day to day lives, so obsessed are they with sex.

Those taking part in circumcision, vaccine, microbicide, pre-exposure prophylaxis (PrEP), treatment as prevention and other trials, many of whom eventually become infected with HIV, are not warned about non-sexual risks. Researchers don't check to see if those who become infected were infected non-sexually or sexually.

In short, most of these trial results are not even valid and certainly do not justify the green light that mass circumcision campaigns have received. Circumcision has not been shown to be of benefit and its safety has not been assurred. The health and even lives of millions of African people are being put at risk by a bunch of well financed Western researchers. Doesn't that bother anyone?

Circumcision: 1.1 Million Kenyans Tricked Into Being Human Guinea Pigs

Some of the highly dubious pronouncements about HIV programs can be taken with a pinch of salt and I certainly hope that's true of the mass male circumcision program taking place among the Luo tribe in Nyanza province, Kenya. About a year ago they were claiming to have circumcised about 100,000 men. Now the figure has risen to 250,000, 40,000 of them said to have taken place over the last few weeks.

The argument is that men are less likely to be infected with HIV if they are circumcised. There is little evidence for this and how, exactly, the process may work, is unknown. But on the slight chance that it may work, the program is going ahead. Aside from the fact that the HIV industry really wants to do it, it is not clear why this program was ever started.

We are constantly told it is 'cost effective' and will prevent hundreds of thousands of infections over the next 20 years. However, this projection depends on a lot of assumptions that are completely unsupported by evidence. And lots of things are 'cost effective', such as reducing diarrhea and intestinal parasite rates, which infect far more people, kill more people and cost even less to prevent and treat. But cost effectiveness doesn't seem to count in those instances.

Male circumcision is rare among members of the Luo tribe and HIV prevalence is high, so this is seen as a good argument for circumcision. However, female genital mutilation (FGM) is also rare. I don't hear anyone calling for mass FGM just because of this correlation. Not that I think FGM is a good thing, I don't. I think it is an appalling form of gender based violence that has none of the benefits claimed for it.

However, two other tribes in Nyanza province, the Kuria and the Kisii, have low HIV prevalence. And most of the men are circumcised. But many, perhaps most, of the women are victims of FGM. And the lowest HIV prevalence found in Kenya is among the ethnic Somalis, who also practice male circumcision and FGM widely.

Clearly, there are other circumstances that surround low HIV rates and high rates of FGM. FGM is most commonly practiced where levels of education are low, people are exceptionally poor and they are isolated from health and other public services. But there are other circumstances high rates of HIV and low rates of male circumcision, too.

Are these arguments for reducing education and health and increasing poverty? I wouldn't have thought so. But if you make projections using the figures for the Northeastern province, which has the lowest HIV rates in the country, you might find that such measures are 'cost effective' when it comes to reducing HIV rates.

Recent research in Tanzania has found that HIV rates are, indeed, lower among women who have undergone FGM of some kind. Indeed, the level of 'protection' given by FGM is curiously similar to that claimed for male circumcision. So if this is not a valid argument for FGM, maybe it's time to reconsider male circumcision?

Given current data, Kenyan Luos are being used in a large scale public health experiment that is undoubtedly unethical. As to the consequences of the experiment, it's too early to say. But if I was a Luo I'd be careful of people wielding scalpels. Just use condoms. You'll still have to do that when you are circumcised, anyway.

Global HIV/AIDS Policy for Africa: Mass Denial of Human Rights

Rumor and myth continue to dominate academic writings about HIV/AIDS, especially when it comes to explaining why HIV prevalence has declined in many countries which have experienced a very serious epidemic. In brief, HIV academics don't really have a clue why the virus spread, peaked and declined in the first place. Therefore, they don't know which prevention programs work and which don't. Some of them may have worked, or they may just have appeared to work because they began shortly before the high death rate stage of the epidemic.

Leaving aside the somewhat risible strategies of abstinence and partner reduction, which were never as vital as the literature claimed, nor as successful, that leaves the one strategy that could have had some impact on sexual transmission of HIV. Using condoms could have been successful if people used them, consistently. But in most places, they didn't. Many people have used condoms, some even use them several times a year. But this is not enough to have much impact on sexual transmission.

A fairly typical set of results comes from Kilifi, in Kenya's Coastal Province. The "mean number of condoms used was 2.2 per person per year among all sexually active individuals". Usage was lower in rural contexts. The majority of people in all East African countries live in rural areas. And not only is condom use lower in rural areas, so is HIV prevalence. There is more than a hint that the extent to which HIV is a mainly sexually transmitted virus has been seriously exaggerated.

Uganda is one of the few countries credited with playing an active part in reducing HIV transmission. The country may have achieved all sorts of feats, it's hard to tell, because rates of transmission there peaked and declined just as mysteriously as they did in other countries. It's just that in Uganda, the epidemic arrived, spread, peaked and declined earlier than it did in Kenya, Tanzania and most of the very high prevalence countries of Southern Africa.

Knowledge about condoms, HIV, unplanned pregnancy and other matters is not nearly as widespread as all the hype suggests. People in urban areas, people with better education and people in higher income brackets know a lot more than people in rural areas. HIV rates being higher in less isolated areas and lower in more isolated areas tends to make popular reduction strategies look a bit pointless.

But I wouldn't like to suggest that higher condom use or knowledge about sex, sexually transmitted infections, unwanted pregnancy, etc, are associated with higher HIV rates, just that they are not particularly relevant to HIV rates. Nor is it to suggest that using condoms to reduce HIV transmission, the transmission of other sexually transmitted infections and unplanned pregnancies is not a good thing.

It's just that HIV is not, as UNAIDS and other 'experts' keep claiming, almost always heterosexually transmitted in African countries (but not in non-African countries). WHO admits on their web site that up to 14% of infections may be spread by unsafe injections and they have unpublished data that suggests such infection rates are even higher. As for the proportion of HIV transmitted by other non-sexual routes, none of these authorities have bothered to check yet.

Given the rates of transmission among intravenous drug users, men who have sex with men and mother to child transmission, the proportion of HIV transmitted through heterosexual sex is in urgent need of investigation. Otherwise there is a danger that these highly inefficient, expensive and deceptive 'prevention' interventions will continue to deflect attention away from the health services that may be causing more infections that they have ever been able to prevent.

A recent paper shows that 50% of the 500,000 people currently infected with HIV in Uganda are under 25. The study also shows that young people know very little about sex, condoms, HIV or pregnancy, despite the hundreds of millions of dollars that have been spent. HIV rates in the area are high. Sadly, young people appear to have picked up many of the rumors spread about condoms by religious leaders, journalists and others who seem to prefer to maintain high rates of STIs and unwanted pregnancies (and the consequent high rates of unsafe abortions).

Firstly, young people need sex education and it needs to be an integrated part of their overall education (not an afterthought tagged on to an already under-resourced system). If religious and political leaders are hell bent on filling people's heads with rubbish (in addition to the bunch of lies they get from the HIV industry), at least with a good education they have some chance of working things out for themselves.

But their education needs to include information about non-sexual HIV transmission routes, such as unsafe healthcare, unsafe cosmetic practices and perhaps some traditional practices that involve exposure to contaminated blood. And in order for this information to be of any use, people need accessible and safe healthcare.

Countries with continuing high rates of HIV transmission can not afford to depend on luck. It is lucky that HIV transmission rates declined. But current rates of transmission are still too high. The HIV industry harping on about sexual behavior and the religious and political interests contradicting every piece of advice given is not going to lead to a reduction in current rates of transmission. As Uganda and other countries are finding, HIV rates can also start to rise again.

In places where very little HIV is transmitted non-sexually, fine, as long as steps are taken to eradicate these forms of transmission altogether. However, it looks as if non-sexual transmission is far from trivial in most African countries. This is in urgent need of investigation and this work can take place at the same time as the work on sexually transmitted HIV. But ignoring non-sexual transmission is probably doing more to spread HIV than continuing the many failed sexual prevention interventions.

The consequences of the lies and inaction from UNAIDS, many HIV/AIDS academics and various institutions are almost too terrible to contemplate. But we can not allow this mass denial of human rights to continue.

The Dogmatic Sexualization of HIV

The main thrust of this blog has been to challenge the 'behavioral paradigm', the view that HIV is almost entirely transmitted by sexual behavior in African countries (The figure '90%' is often bandied about but there is no evidence for it). Therefore, any articles that either support or challenge the behavioral paradigm are of particular interest. As for the belief that the paradigm only holds for African countries, it is difficult to see that as anything other than racism.

A group of people led by Munyaradzi Mapingure have published a paper suggesting that the behavioral paradigm may need to be reconsidered in the light of their findings. They discuss sexual behavior data for Zimbabwe and Tanzania which clearly does not correlate with HIV prevalence. Zimbabwe has some of the highest HIV rates in the world while Tanzania has relatively low HIV prevalence. Yet levels of 'unsafe' sexual behavior are far higher in Tanzania than they are in Zimbabwe.

This lack of correlation between HIV and sexual behavior considered to be unsafe is not rare. There have been many instances of it over the years, in many countries. But few researchers have used the lack of correlation to question the behavioral paradigm. In 2003, a number of researchers published papers suggesting that HIV may not be as closely connected with sexual behavior as HIV prevention programming would lead one to believe. The HIV orthodoxy has yet to refute the body of evidence.

Mapingure and colleagues find that "women in Tanzania reported more risky sexual behaviour than women in Zimbabwe, which is opposite to what is reflected in the HIV prevalence. Prevalence of risky sexual behaviour characteristics, such as having had a casual sexual partner in the previous 12 months, having had more than one lifetime sexual partner, early sexual debut, being in a polygamous relationship and having siblings by different fathers, were all higher for Tanzania. Alcohol consumption, which increases the tendency to engage in risky sexual behaviour, was also more common in Tanzania than in Zimbabwe."

The authors conclude :"Clearly, sexual behaviour only cannot explain the observed differences in HIV prevalence between the two countries" and ask how this "paradox" can be explained. But there is no paradox. They even discuss other papers which make it quite clear that the behavioral paradigm was never in the least bit tenable. Every few years, detailed data on sexual and other behaviors in African countries are found not to correlate with HIV prevalence (check the Demographic and Health Surveys by country).

This paper suggests a few reasons why their results appear paradoxical but the authors seriously consider the possibility that non-sexual HIV transmission might be playing a part in Zimbabwe (which doesn't rule out the possibility of non-sexual transmission playing a part in Tanzania, also). They qualify this possibility by suggesting that such transmission would have been more likely in the 1980s, before the dangers of unsafe medical procedures were widely recognized.

HIV epidemics such as the ones in Zimbabwe, Swaziland, South Africa and others suggest that rates of transmission were probably still high well into the 1990s and perhaps the 2000s. The dangers of nosocomial transmission of HIV, transmission from unsafe medical procedures, may have been recognized a long time ago. But there is little evidence that this form of transmission was successfully eradicated in any sub-Saharan African country. It is more likely that relatively low HIV prevalence in Tanzania is a result of very low access to health services.

Conversely, higher access to health services in Zimbabwe could go a long way towards explaining the incredibly high rates of transmission seen there. And the rates really are incredible. Given the low transmission probability for sexual transmission of HIV per sex-act, Zimbabweans would need to do little else but have sex to explain national prevalence, which reached almost 30% at one time.

In an article commenting on the above paper, Mapingure says "early in the epidemic, syringes weren’t sterilized properly". WHO has recently accepted that as much as 14% of injections are unsafe. Disposable syringes are being reused, either because they are in short supply or because supplies are not reaching their target. Also, health workers are probably not fully trained in making their practices absolutely safe. Published Health Service Provision Assessments make it clear that many Kenyan and Tanzanian health facilities do not have the capacity to eliminate nosocomial infections.

He concludes “Most HIV prevention programmes are failing because they focus on sexual behaviour. We need to look at the whole sexualization of HIV.” This is not just a challenge to the behavioral paradigm. It is a challenge, a long overdue challenge, to the whole of the HIV orthodoxy. UNAIDS and those tasked with reducing the spread of HIV have failed miserably. To this day, they refuse to accept the possibility that non-sexual transmission of HIV is the only thing that can explain the huge differences in prevalence found between and within different countries.

UNAIDS' Obsession with Sex Helps Spread HIV

According to an article in Tanzania's Citizen newspaper, there is 'growing concern' that HIV transmission is increasing among those in long term relationships and in marriages. Yet HIV prevalence has been high in these groups for a long time. Tanzania may not have carried out a Modes of Transmission Survey recently, as Kenya and Uganda have done. But the three countries have similar epidemics.

The advice that having sex with a long term partner or spouse will protect you from HIV has never been quite true. 'Safe' sex practices may include reducing the number of partners you have and various other measures, such as using condoms, avoiding sexually transmitted infections, etc. But HIV is not, and has never been, solely transmitted sexually. It is also transmitted through unsafe medical practices, such as unsterile injections, traditional medicine, cosmetic practices, such as shaving and tattooing and perhaps other means.

Telling people that they will be protected from HIV if they 'abstain' from sex or obey any of the other paternalistic strictures of the predominantly right wing 'Christian' prevention programs that dominate African country HIV strategies is extremely unethical. Since HIV was first identified, it was clear that it was mainly transmitted through contaminated blood. Sexual transmission was also recognised, especially through anal sex. But the risk of transmission through heterosexual sex was and is quite low.

People are entitled to know that if someone is HIV positive, this does not mean they are promiscuous. You can not tell how someone was infected with HIV without investigating, and even then, the exact cause may still remain unclear. It is worth bearing in mind that heterosexual sex is not an efficient transmitter of HIV. But contaminated blood is a very efficient transmitter.

Many people who are HIV positive are unaware of how they were infected and assume that because they are not virgins, they must have been infected sexually. However, they need to find out if their partner is infected. And even if their partner is infected, they may still not have been infected sexually. It's perfectly possible to be infected through unsafe injections, say, even though your partner was infected sexually.

It is vital that people are made aware of the risks they face and the steps they can take to reduce those risks. They need knowledge, skills and empowerment to be able to ask health and other professionals for evidence that they are observing all safety guidelines. This is necessary to ensure that neither HIV nor any other blood borne infections are transmitted during routine procedures. If people don't know about nosocomial HIV infection, infection through unsafe medical procedures, they will not be alert to the risks and will not take steps to avoid them.

It is heartening to hear that some have made the connection between exposure to contaminated blood and HIV transmission. A group in Kenya, and more recently in Tanzania, has recognised that HIV can be transmitted if care is not taken removing jiggers. This is often done using an unsterilized safety pin or other sharp object. If the object is then used on other people, there is a considerable risk of transmitting HIV and other viruses. Even if a virus is not transmitted, serious infections can result.

But despite small numbers of people in Kenya and Tanzania knowing that HIV is not just transmitted sexually, UNAIDS and others in the HIV industry are reluctant to accept the importance of non-sexual transmission. Official figures estimate that transmission through unsafe medical practices is very low. As a result, only a tiny fraction of the billions being ploughed into HIV prevention goes towards non-sexual HIV transmission.

Exactly why UNAIDS and the rest of the industry wish to ignore non-sexual HIV transmission is not clear. But the organization has always been pretty irrelevant to the HIV pandemic. With our without UNAIDS, people need to recognise the most common and the most serious risks they face. HIV is not just about sex and it has never been just about sex. Anything that involves exposure to blood or certain other bodily fluids can carry a risk of transmission of HIV and other viruses.

[For more about UNAIDS' and the HIV industry's obsession with sex, see my other blog.]

Effectiveness of Circumcision in Preventing HIV Has Not Been Demonstrated

The Journal of Medical Ethics [apologies for citing it as BMJ, earlier] has an uncharacteristically sane article on male circumcision as a proposed means of reducing HIV transmission, a subject that seems to attract an amazing number of nutters. The HIV industry in general is crazy about mass male circumcision campaigns and some barely credible claims have been made about how many operations have been carried out in Kenya. Let's hope they have been exaggerated, like so many HIV related statistics in Kenya.

This JME article reminds us that a 2009 Cochrane review about the effectiveness of the operation in preventing HIV transmission may have found some evidence but it also called for further studies into feasibility, desirability and cost-effectiveness. Until these studies have been carried out, mass male circumcision is still an unknown quantity. Despite this, numerous articles, by journalists and health professionals alike, have spewed out pronouncements about how this operation will turn around the epidemic.

Even if it works, it will not turn around the epidemic. It may even increase transmission. Kenya's hospitals have an unenviable reputation for cleanliness and hygiene and the reputation of other high HIV prevalence countries is no better. At present, HIV prevalence among men is often substantially lower than it is among women in many demographic sectors and among many tribes. But that is unlikely to remain the case.

So there are two main problems (although these are not the ones dealt with in the JME article). Firstly, circumcision is unlikely to prevent HIV transmission through heterosexual intercourse to any great extent and it may even increase it.

And secondly, a very significant proportion of HIV is probably being transmitted through non-sexual routes. According to WHO, 14% is transmitted by unsafe injections. Other forms of medical transmission are likely to make an additional contribution.

There are several other non-sexual routes, such as unsafe cosmetic practices. And the number of transmissions from mother to child is extremely high in high prevalence countries, despite antiretretroviral drugs being widely available for some time. Also, there is a lot of transmission through intravenous drug use in some countries.

The hype about circumcision is quite extraordinary, considering that the people who are most in favor of it should also be most aware of the reasons why the approach is flawed. They should be aware of conditions in hospitals, the fact that sexual transmission of HIV has been wildly exaggerated, the fragility of the handful of field trials that have been carried out and the statistically insignificant effect of circumcision in many countries.

The fact that countries where circumcised men are more likely to be infected than uncircumcised is usually not mentioned is disturbing. But those who express their support for circumcision must be aware that they have been quite selective in the figures they cite.

The JME article questions the ethics of advocating an intervention for which the evidence is highly questionable. It makes it quite clear that there is, as yet, insufficient evidence to proceed with such an intervention. Yet, if some sources are to be believed, well over 100,000 circumcision operations have been carried out in Kenya's Nyanza province and tens of thousands in other countries.

Not content with imposing the operation on adults, there is even talk about imposing it on infants as well. This is supposed to 'protect' them from HIV transmission through unsafe sex. Not only are they probably not at risk of infection through unsafe sex once they become sexually active; but people are being led to believe that they are safe from HIV if they take a handful of precautions that could only, at best, protect them from sexually transmitted HIV. None of these precautions will protect them from non-sexually transmitted HIV, the very possibility of which is often barely mentioned.

The behavior of the circumcision advocates is unethical in promoting an operation that will have minimal benefit. But they are also at fault in failing to inform people about the extremely high risk of being infected through unsafe healthcare. This results in people being unaware of how to protect themselves from healthcare transmission of HIV, hepatitis and various other infections. Such nosocomial infection is very common, but it is rarely mentioned in the literature.

The best known method of reducing HIV transmission through sexual intercourse is correct and consistent use of condoms. Even after circumcision, men need to continue to use condoms correctly and consistently, otherwise there is no guarantee the intervention will have any benefit. Advocates of circumcision would be better off forgetting about circumcision if they really wish to reduce HIV transmission and just concentrate on condoms. The worrying thing is, they are already well aware of these considerations but they behave as if they are oblivious to them.

Are We About to Take the Biggest Step Yet in Reducing HIV Transmission?

Recently, I blogged about WHO's estimates for the number of people infected every year with HIV through unsafe injections and wondered why the number, 23,000, was so low. It was an error in the original reporting. In fact the number is 260,000 HIV infections. In addition, unsafe injections account for millions of transmissions of hepatitis B and C and a host of other diseases.

To put this in perspective, just under 10% of HIV in Uganda is transmitted via sex workers, their clients and their clients' partners, all together. The figure for Kenya is about 15%. But the contribution of unsafe injections is estimated at about 14%, and it could be a lot higher in some places.

The majority of HIV positive people in high prevalence countries did not engage in 'unsafe' sex, according to Modes of Transmission Surveys. But you'd never think that when you read articles about sexual behavior and commercial sex work. The percentage actually attributed to sex workers is less than 2%. It's the clients and partners of clients who make up the bulk of that 10% figure.

Despite sex playing a far smaller role in the AIDS pandemic than we are led to believe by most media and academic writings, the evidence that something else is playing a big part is all around. In South Africa, farm workers in two provinces have some of the highest rates ever found anywhere, almost 40%. Compare this to HIV prevalence among sex workers in India, which stands at about 7%. That's about the same as national prevalence in Kenya, Tanzania and Uganda. Are we supposed to conclude that some Africans engage in far more unsafe sex than Indian sex workers?

The Institute of Migration study, apparently, "could not pin-point a single factor causing this high rate of HIV infection on these farms but points instead to a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of Sexually Transmitted Infections (STIs) and/or TB and high levels of sexual violence". But these factors are present in many places in the world, in developing and developed countries, without giving rise to such astonishing HIV rates.

Dr Eric Ventura says that more research is clearly needed. But perhaps some different research is needed and even some investigation of the results of some already completed research. Not that there isn't plenty of research into non-sexual transmission, but UNAIDS and many others in the HIV industry choose to ignore it. Perhaps now that WHO have seen the light, UNAIDS will follow. But Ventura suggests, among other things, increasing farm worker acces to healthcare.

Perhaps access to healthcare is the biggest problem in South Africa and some of the surrounding high prevalence countries. Most of the very high HIV prevalence African countries have better access to healthcare than some of the medium prevalence countries, such as Kenya, Tanzania and Uganda. But what quality of healthcare? Increasing access to healthcare will be counterproductive if poor healthcare is contributing more to the pandemic than commercial sex, which has been such a popular punchbag up to now.

Very slowly, the issue of injection safety and other forms of non-sexual transmission of HIV is being raised and even being picked up by the media. The above figures about unsafe injections were supplied by Safepoint Tanzania, who have been trying to get this vital topic on the agenda. But when it comes to media attention, or even that of the HIV industry, sex always trumps boring old healthcare.

With all the interest in criminal HIV transmission (through 'unsafe' sex, of course), I wonder if we will ever look back on the days when UNAIDS and others tasked with reducing HIV transmission consistently refused to accept that a very significant proportion was coming from unsafe injections and ask ourselves how they could get away with this? Because what they are getting away with now constitutes professional negligence that far exceeds that of those who continued to use blood products contaminated with HIV long after they knew the risks.

As another World AIDS Day looms and the 'experts' drone on about what a brilliant job they have been doing, it's time to take what will be the biggest single step ever towards reducing HIV transmission in African countries. That is to recognize that HIV is not just about sex, unsafe or otherwise, and by acting to eliminate the most avoidable and preventable factors in the spread of the virus: unsafe injections and other healthcare procedures.

UNAIDS' Report: Prejudice, Wishful Thinking, Slick Marketing & a Veneer of Pop Science

World Aids Day is almost upon us, so the industry has to get its story together. It's clear that rich countries of the world have other things on their minds, such as money, so UNAIDS and their chums are not expecting them to be quite so generous in the near future.

But they have already adopted a new strategy: instead of constantly whining about the pandemic getting worse and the industry needing more money, they have started to whine about how the pandemic is getting better, so they need more money to keep things on the right trajectory.

"We have halted and begun to reverse the epidemic. Fewer people are becoming infected with HIV and fewer people are dying from AIDS", says the forward to UNAIDS' annual epidemic report. "But", it goes on, "we are not yet in a position to say 'mission accomplished.' Growth in investment for the AIDS response has flattened for the first time in 2009. Demand is outstripping supply. Stigma, discrimination, and bad laws continue to place roadblocks for people living with HIV and people on the margins."

Global press, observing the usual custom of repeating press releases without change, analysis, question or thought, are now busy saying what they are told to say. "HIV epidemic 'halted', says UN" says the BBC. The other news agencies I looked at appear to be in accord. But what UNAIDS are claiming is that the pandemic has been halted by their efforts; and there is precious little evidence that that is true.

HIV incidence in all the highest prevalence countries began to fall some 10 or 15 years after the virus started to spread. (Incidence is the annual rate of new infections, prevalence is the proportion of individuals in a population who have HIV at a specific point in time.) This means that incidence in Kenya began to decline in the early to mid 1990s and in Uganda several years earlier. In Southern African countries, where HIV arrived later, the peak and subsequent decline was also later.

In fact, there are usually different sub-epidemics in countries and each one probably started, peaked and declined at different times. In Kenya, Uganda and Tanzania, national declines in incidence were followed by a peak in prevalence and then a rapid decline in prevalence as death rates started to climb. Once death rates peaked and declined, prevalence rates started to look as if they were going to go up again. So these three countries still have high enough rates of transmission to ensure that HIV will be endemic there for the foreseeable future.

But the most disturbing thing about this sort of epidemic dynamic is that we have no clear explanation of why HIV transmission peaked and started to decline long before anyone had got around to doing anything to reduce transmission.

Yes, we hear lots of triumphalist stories about what happened in Uganda, where HIV prevalence hasn't changed in years and is probably now increasing. We also hear that prevalence rates in some countries are static, or even climbing, because there are many HIV positive people being kept alive with antiretroviral treatment (ART). Some of the stories about Uganda may be true and there is little doubt that many people are being kept alive by ART.

But these don't explain why incidence peaked and declined. It also leaves the problem of why a disease that is difficult to transmit sexually is said to have suddenly started to spread at alarming rates in the 1970s, 1980s and 1990s without any apparent (and quite astonishing) increase in sexual behavior.

There is no evidence that rates of sexual behavior were ever high enough (or could ever be high enough) to give rise to such rates of transmission. Nor is there any evidence that rates of sexual behavior then declined as a result of some half baked behavior change programs, which few people still believe had any real impact.

In many non-African countries, where sexual behavior was never given as the entire explanation of how HIV became endemic, rates of transmission are rising. HIV transmission in these countries is more likely to be a result of intravenous drug use (IDU) and anal sex, homosexual and heterosexual. In non-African countries, HIV transmission rates correspond quite convincingly with levels of IDU and men having unprotected sex with men (figures for heterosexual anal sex are not so clear). Both IDU and anal sex are very efficient modes of HIV transmission.

The annual presentation of the industry orthodoxy as if it were infallible is bad enough. It's little more than a mix of prejudice, wishful thinking, slick marketing and a veneer of pop science. But it's insulting to people who suffer from HIV and AIDS, directly and indirectly, to be told that almost everything that can be done is being done. And it will be of little comfort to those who are at risk of becoming infected, either.

The 'hypothesis' about HIV arriving out of the blue, being spread by those highly sexually active Africans, then declining because some clever Western scientists told them to stop having so much sex doesn't work. But like any other lie, it requires more lies to shore it up until the liars come to realize that they are reaching the end of the credibility tether.

It remains to be seen how many people will be unnecessarily infected before UNAIDS and Co. tell the truth. Hopefully, they will then be abolished and replaced by an institution that is not entirely run by vested interests.

Is the 'War' on HIV/AIDS a War on Africans?

As in the broader field of development, who gets what in HIV funding depends more on their relationship with Western powers than on relative need. Certainly what is wanted, what is requested or what is appropriate are not considered. You might say that the market is supply driven, whether you are talking about HIV programs, services, commodities or even research.

A country run by a pretty undemocratic regime, like Uganda, is vaguely listened to and receives a lot of funding. Zimbabwe, which may also have questionable levels of democracy, is not considered particularly credible and receives a lot less funding. Yet it's hard to know which country is the better or worse off. The populations of both countries are infantilized, manipulated and patronized.

But both countries have little say in how HIV, people infected with HIV or people at risk of being infected with HIV are treated. The myth of 'individual responsibility' is pushed by vested interests, political, commercial and religious. All Africans are vilified by the HIV dogma, in particular, women. At best, women are seen as helpless victims of the reckless male, who is seen as violent, greedy and lazy. At worst, women are seen as sexually promiscuous, ignorant and unconcerned about their health or the health and welfare of their children.

Social problems are, rather tautologically, undesirable. Persecution, rape, poverty, disease, discrimination, deprivation and many other social problems are exacerbated in developing countries by poor health services, low levels of education, underdeveloped infrastructure, high unemployment, etc.

But many social problems in African countries have been associated with the spread of HIV. The truth is, no social problem is, on its own, responsible. HIV is not driven by any particular social problem, though many social problems may play some part in HIV transmission. HIV is a virus and, in common with other viruses, its spread relates to the nature of the virus itself, the virus host and the environments in which the hosts live.

Sometimes, the ostensible driver of HIV in African countries is given the name 'African culture', sometimes 'African sexuality' (assumed to be a subset of human sexuality, but very different), sometimes the 'African male psyche' (in the case of the Zimbabwean male). All the undesirable characteristics assumed to spread HIV are also assumed to make up whatever culture, sexuality or psyche is being described.

The fact that HIV epidemics vary considerably within and between countries, along with culture and sexuality, is generally ignored. As for psyche, the notion is woolly even by pop anthropological standards.

Kenya even had a special profile for members of the Luo tribe, who were historically deemed to be incapable of leadership for various reasons, including lack of male circumcision. And when HIV was recognized and found to infect far more Luo than members of any other tribe, this was conveniently added to the set of prejudices. Exactly why HIV prevalence is higher among the Luo population is not yet clear. Nor do the HIV research community seem particularly interested. Following the various prejudices, HIV policies are painted with broad brush strokes.

Zimbabwe may not receive the same level of Western favor as Uganda, but they (and a number of other African countries) are being 'favored' with a similar mass male circumcision program, funded by USAID. This program is not based on any demonstrated need for mass male circumcision, nor any demonstrated effectiveness of such a program in Zimbabwe (or any other African country). It simply assumes that the country is dominated by African males who conform to the stereotype, whatever set of undesirable characteristics that currently comprises.

One of the most studied HIV epidemics in Africa is in Uganda, where early HIV prevention campaigns have gained mythical status. But Uganda still has a serious HIV epidemic. If it was overstated in the 80s and 90s, it is probably understated right now. HIV has not been shown to relate to sexual behavior alone, and certainly not to any particular 'psyche', culture or sexuality. On the contrary, no single 'driver' has been identified in Uganda. It's almost as if the epidemic struck, increased, decreased and then increased again, independent of any prevention effort, national or global.

There may be people doing undesirable things in Zimbabwe, Uganda, Luo populated areas and certain other African countries. But this is true of every country in the world. Similarly, HIV may well be spread by sexual behavior, especially certain forms of sexual behavior. But sexual behavior, including sexual behavior considered to be 'unsafe', is universal.

On the other hand, in every country in the world, HIV is also known to be spread by certain non-sexual modes, such as through unsafe medical and cosmetic procedures. When virgins, people who are not sexually active, people who have only had 'safe' sex, infants whose mothers are not HIV positive and others in non-African countries are found to be HIV positive, the cause of their status is investigated. But in Africa, it is merely assumed that personal testimony is less reliable than it would be in non-African countries.

UNAIDS and the rest of the HIV community refuse to countenance suggestions that HIV in Africa has anything to do with, for example, medical facilities. This is despite the fact that medical facilities in some African countries are among the worst in the world. Nosocomial transmissions of HIV have probably been found (and investigated) in all wealthy countries, where health facilities are far better. But where such transmissions may have occurred in African countries, the authorities close ranks.

Zimbabwe, along with several other high HIV prevalence countries, is exceptional. These countries, including Botswana, South Africa, Swaziland, Lesotho, Zambia and perhaps others, have relatively good medical facilities, with high levels of access. And that may turn out to be one of the decisive factors in high HIV prevalence countries. Health facilities are better than in Uganda, Kenya, Tanzania and other medium prevalence countries, where access to health facilities is low.

If HIV programming is, as I have suggested above, supply driven, it seems like the Western countries who dominate development, health and HIV agenda are not really interested in any of those issues. Perhaps it's even naive to expect that Western countries would have interests that go beyond their own welfare. But HIV programming is often referred to as a 'war', or in similar terms, when it looks a lot more like a war against Africans. I'm not saying the West created HIV, just that they seem intent on making sure it is not going to be eradicated too soon.

Would You Risk HIV While Pregnant or When Planning a Family?

South African's City Press has an article entitled 'Survey finds staggering HIV rate in pregnant women'. And the figures are, indeed, staggering. National prevalence among pregnant women is almost 30%. Rates have been stable for several years and the health minister wishes to see prevalence decrease to 17.3% by 2015. Of course, this is unlikely unless death rates reach equally spectacular levels.

But what is really staggering is how one could believe that so many women who intend to have children or who are already pregnant would risk contracting HIV and possibly passing it on to their child, in addition to having to live with a life-threatening disease themselves. Doesn't that strike anyone as odd?

Many African women are infected when they are already pregnant, often well into their pregnancy. Are we supposed to believe that so many people wish to have a child but don't really care whether that child will live or whether the child will lead a healthy life?

Frankly, I don't believe that South Africa, or any other country in the world, is populated by so many people who don't care whether they or future generations continue to suffer from this terrible pandemic, which is hundreds of times worse in some sub-Saharan African countries than it is anywhere else.

Try thinking about it: you want to get pregnant or you are already pregnant, intentionally or otherwise; and you take many risks and no precautions towards ensuring your own safety or the safety of your child. This would require total ignorance or total heartlessness. Are we seriously suggesting that so many people in South Africa are either ignorant, heartless or both?

Transmission rates among pregnant women in South Africa and other African countries cannot be explained by sexual behavior, no matter how much sex people are having and no matter how 'unsafe' it is. These rates could only be explained by some efficient mode of transmission, such as nosocomial transmission. This is where the disease is transmitted through unsafe medical practices.

I have mentioned it before but it's worth repeating: the WHO estimates that 70% of medical injections in sub-Saharan African countries are unnecessary. And almost 20% of injections are unsafe.

Pregnant women attending ante-natal clinics in African countries get a lot of injections. Often, their babies also get a lot of injections. There is ample opportunity for high rates of transmission in countries where HIV prevalence is high and safety standards are low.

To believe that HIV is being sexually transmitted among pregnant women at such high rates is to believe appalling things about African women (and probably men, too). In short, to believe such things is to be a racist, a sexist and probably much else that's not very pleasant.

Not only do Africans behave sexually much like other human beings, they also place value on human life, especially their own and those of their children. Just what are those who believe HIV is almost entirely sexually transmitted in African countries trying to say about Africans?

If Counselling and Condoms Are So Effective, Why Bother With Circumcision?

Male circumcision enthusiasts once worried that men who were circumcised as adults in order to reduce their susceptibility to HIV infection might subsequently engage in risky sexual behavior. This phenomenon is called 'risk compensation'. It was feared that men would only undergo the operation if they could then safely have sex without a condom, even though circumcision is only claimed to be 50-60% effective, at best.

While the evidence for the protective effects of circumcision are not very convincing, I'm surprised anyone would undergo the operation at all if they still have to use condoms afterwards. If you have no aversion to using condoms you'll probably still use them after the operation. But if you have an aversion, you are unlikely to lose it as a result of the operation.

Now the enthusiasts are claiming, on the basis of a survey of a handful of people (30, with a plan to circumcise over one million), that risk compensation is not occurring. They also claim that people are having safer sex after being circumcised because the counselling, pre- and post-operation, is so good. But then the question is, why could everyone not just receive counselling on its own?

If being circumcised gives little or no benefit unless you use condoms and avoid other risks, why not just advise everyone to use condoms and avoid other risks? The operation seems like an expensive and unnecessary burden on both clients and health services. Condoms on their own provide the highest level of protection against sexual transmission of HIV, whether you are circumcised or uncircumcised.

It's worth noting, those who were circumcised in traditional ceremonies do not receive the sort of counselling that those being circumcised in hospitals are getting. Yet there is no evidence that those circumcised in traditional settings are less well protected than those circumcised in hospitals. So it sounds as if the author of the study, Thomas Reiss, is going well beyond the evidence in making his claims about the effectiveness of both circumcision and the accompanying counselling.

Another article talks about risk compensation in connection with people on antiretroviral drugs (ARV). Again, it was feared that people would engage in 'risky' sex once they were on AIDS treatment. This would be tempting because they are said to be far less likely to infect others if they are responding well to the drugs.

This article is based on a study by Neil Martinson and it also puts low risk compensation behavior down to the experience of 'staring death in the face', in addition to 'counselling and safe sex messages'.

Treatment is a vital element in a country's overall AIDS strategy, as are counselling and other measures. But these two articles give the impression that sex, safe or otherwise, might not be as important a factor in African HIV epidemics as we are led to believe by the HIV industry mainstream. People may well be reacting to all the fuss about sex, but perhaps they were never as sexually incontinent as UNAIDS and their followers claim.

There is a proposal to test everyone in a population regularly and immediately put those found to be HIV positive on ARVs, called 'test and treat'. It has been found that the immune response in those on treatment can be so high that they can even have unprotected sex with a HIV negative partner without much risk of transmission.

If conditions are such that a test and treat strategy can be implemented in developing countries, perhaps in conjunction with various types of counselling, support and condom use, this may reduce sexual transmission of HIV considerably. Non-sexual HIV transmission may continue, unless it is reduced by appropriate measures. But the success of these efforts to reduce HIV transmission depend a lot on the accuracy of researchers and the extent to which policies are based on genuine findings, rather than on a political gloss.

HIV policy in African countries, up to now, seems to have been based more on wishful thinking and a completely unwarrented assumption that Africans are far more promiscuous than non-Africans. The two articles above don't give much cause for optimism. Evidence suggests that HIV is not solely, perhaps not even mainly, driven by sexual behavior. Technical fixes, like ARVs and mass male circumcision, only target sexual transmission of HIV. And they may not even be particularly effective in that respect.

African HIV Pandemic: Do Condom Manufacturers Worry About Bad Press?

I've asked the question a number of times, most recently on my other blog about pre-exposure prophylaxis (PrEP): why are condom manufacturers not worried about some of the bad press they are getting in one of their biggest markets in the world, sub-Saharan Africa?

Several microbicide trials that have shown the gels to be of little or no use have also shown that people who don't have sex very often, don't engage in much 'unsafe' sex and almost always use condoms, still become infected with HIV. Heterosexual sex is not a very efficient transmitter of HIV, so why do condoms seem to fail so badly during these trials?

For those who reject the behavioral paradigm, the claim (it's not a belief, those who make the claim know it's not true) that almost all HIV is transmitted through heterosexual sex in African countries, there is no conundrum. Those who become infected with HIV under the circumstances listed above were unlikely to have been infected sexually.

There are a number of other ways they could have been infected. They are unlikely to have been intravenous drug users, unless the trial screening process was highly flawed! But they probably received some kind of invasive medical treatment, such as injections.

Unsterile medical injections are a very efficient means of transmitting HIV and other blood-borne viruses, especially in high HIV prevalence areas, where these trials tend to be carried out.

The problem is that the trial protocol didn't involve investigating how participants became infected. The protocol could have attempted to determine the risks that people in the area faced because if people were being infected by any other route aside from sexual intercourse, that would invalidate the results of the trial.

This is where the condom manufacturers should be coming in. Trial results show that rates of HIV infection are very high, even among people using condoms. But if people are being infected via unsafe medical injections, cosmetic procedures such as tattooing, or anything else, this does not indicate that condoms have failed.

The denial that non-sexual HIV transmission could play a part in high prevalence countries leads to a lot of confusion. A group of people in Nigeria, along with a HIV research foundation, are suing the government for promoting condoms because they 'didn't work'. Members of the group used them but still ended up HIV positive. They are demanding $50 billion in compensation and an order against further promotion of condoms.

They should be demanding an investigation into how they might have become infected. Condom manufacturers should also be demanding such an investigation. Because every country in the world is, at least to some extent, promoting condoms as a means of preventing HIV transmission. Few seem to realise the non-sexual risks they face, even though they may be aware that condoms will not protect them from these.

As a result, HIV is still spreading quickly and will continue to do so for the forseeable future. Condoms are not the problem. They have a pretty high success rate when it comes to preventing sexually transmitted HIV. But they are not relevant when it comes to non-sexually transmitted HIV and it's important that this be made clear.

Condom manufactures should be very worried about the misrepresentation involved here. Their products are being promoted in circumstances where they are guaranteed to fail. Some day other people, like this small group of Nigerians, will start to ask why they are HIV positive even though they have not been exposed to any possibility of sexual transmission.

Of course, it's not the business of condom manufacturers to inform people that condoms won't prevent non-sexual HIV transmission; that should be pretty obvious already. But unless people are informed of the probability of their being infected non-sexually, the probably currently being unknown, it will continue to appear as if the billions of condoms being supplied to African countries are not having much impact.

Condoms are about the only hope that people in African countries have when it comes to preventing HIV transmission through sexual intercourse, whether vaginal or anal. They are vital in the overall public health goal of cutting transmission. But there is also a need to establish levels of non-sexual HIV transmission and to implement public measures to prevent it. If condom manufacturers wish to continue to receive billions of dollars of public money, they should help to make the distinction between sexual and non-sexual HIV transmission clear.

People need to know the whole story about HIV: it is not just transmitted sexually and they will not be protected if they think it is. They need to know that HIV can also be transmitted through unsafe health care and cosmetic procedures; they need to know how to avoid this sort of risk; and the risks people face in medical and cosmetic facilities need to be reduced. There is nothing to be gained from emphasizing sexual risks and completely ignoring non-sexual risks.