A little while back, I blogged about research that identified HIV prevalence 'hotspots', where high figures were clustered together. This research, carried out in Lesotho, looked at hotspots for males and females and found that they were spatially distant, which may seem anomalous for what is said to be a mainly sexually transmitted disease.
Similar work carried out in South Africa was a bit disappointing. Because, even though it is well known that fewer men are infected than women, often far fewer, this research by Handan Wand and Gita Ramjee only looked at hotspots of high HIV prevalence and incidence for women [Apologies for providing the wrong link yesterday.] Excluding men from such research is odd if it is assumed that women are mainly being infected by men.
But it clearly is assumed that all, not just almost all, transmission is through sex. "At all visits, all participants received counselling on risk reduction and as many male condoms as desired. Counsellors emphasized that condoms are the only known method to prevent HIV and sexually transmitted infections (STIs), and that condoms should be used for every act of sex."
There is something small but crucial wrong with this statement: condoms are the only known method to prevent sexually transmitted HIV. But using condoms during sex will not protect against non-sexually transmitted HIV, which could result from unsafe health care or unsafe cosmetic practices.
Indeed, failing to inform people about non-sexual risks means that they are unable to protect themselves from them and this could be a reason why HIV prevalence is so high in some sub-Saharan African countries. Pretending that HIV is always (or even almost always) sexually transmitted flies in the face of all evidence and is probably responsible for a substantial proportion of all transmission.
As for this research, it found some significant correlations between being HIV positive and certain types of behavior considered to increase the risk of being infected with HIV. 'Significant' in the strict statistical sense of the word, but not particularly large correlations. A non-statistician might think the data needs to be re-examined in the light of such apparently minor differences but not our intrepid authors.
For example: "The proportion of women who reported being legally married was significantly higher among those outside the hotspots than within them (16% vs. 12%, p = 0.001). Significantly more women in the geographical hotspots reported being Christian (94% vs. 90%, p < 0.001) and speaking Zulu at home (91% vs. 86%, p < 0.001) compared with those in non-cluster areas."
The article goes on: "The spatial clustering of HIV cases was found to be related to certain demographic and risk behaviours. Number of male sexual partners was not collected in this study; however, being single, combined with high frequency of sexual acts, gives strong evidence for those women having multiple partners, as well as possibly engaging in transactional sex."
'Strong' evidence? How does this 'high frequency of sexual acts' compare to countries with low HIV prevalence? The same question regarding 'multiple partners'? And would the authors come to the same conclusion of 'possibly engaging in transactional sex' if the risk factors in a low prevalence country were similar? I don't think so.
The authors may be leaving the door open to further research about the safety of health care facilities, but then again, they may not: "These results may be due to fundamental differences between the communities with regard to health care centres, population density and other socio-economic factors. These data provide new evidence to support the need to investigate potential sources of infection and to study transmission patterns in the community in order to apply relevant interventions for prevention of this devastating disease."
Let's hope that 'relevant' interventions means interventions that prevent non-sexual as well as sexual transmission, but it doesn't look as if these particular researchers will see things that way.
It is concluded that "Information on the spatial distribution of populations and services is essential to understand access to health services." But if some HIV is being transmitted nosocomially, as a result of inadequate health facilities, this also needs to be established. Otherwise increasing access to health services could result in higher rates of HIV transmission.
The authors don't just need to "determine and target the specific communities that are most in need of education, prevention and treatment activities", they also need to determine exactly what sort of education and what sort of prevention activities are required. Otherwise, at best, things could remain as bad as they are and atworst, they could get a lot worse. Neither of these would be good for South Africa.
Showing posts with label commercial sex work. Show all posts
Showing posts with label commercial sex work. Show all posts
Monday, April 18, 2011
Tuesday, March 22, 2011
HIV in Lesotho: The Unpopular Questions Are in Most Need of Answers
Yesterday I blogged about HIV in Lesotho and the finding that clusters of high HIV prevalence for women and clusters of high HIV prevalence for men do not overlap very much. I wrote to the corresponding author of the finding, Myong-Hyun Go, to ask if the extent to which HIV is transmitted sexually might thereby be in question. His reply was a definite no, but without any argument or evidence.
And that's pretty much how the HIV industry works. The view that HIV is mainly transmitted heterosexually in African countries is sometimes called the 'behavioral paradigm'. And it is not really amenable to evidence, for or against. It is, let's be frank, a prejudice. So it is worth looking a bit more closely at some figures for HIV in Lesotho.
The study in question uses data from the 2004 Lesotho Demographic and Health Survey (DHS), but as the 2009 survey is available, I'll be referring to it instead. After all, the authors expect their work to influence health policy, so it would need to apply equally to both early and later data.
In common with many other African countries, women usually report very low levels of multiple sex partners, with less than 10% having more than one partner in the previous 12 months and a mean number of lifetime partners never exceeding 3. And while HIV prevalence differs a lot spatially, levels of multiple sex partners and mean number of lifetime partners does not.
Men usually report far higher levels of multiple partnership, double or even triple the levels for women. Their mean number of sexual partners is also up to three times higher. Such differences are equally pronounced among young people. Yet far more women than men are HIV positive in most age groups and in most areas. This is also the case in other African countries.
HIV prevalence by sexual behavior figures show that orthodox thinking about age at first intercourse is in need of review. For women, those who first have sex at less than 16 years old have the same HIV prevalence as those who start at 20 years or over. For men, prevalence actually rises with age, with those starting early having lower prevalence. Prevalence for men and women who use condoms is about the same as it is for those who don't.
But the most remarkable thing about the figures is not that HIV prevalence does or does not correlate with sexual behavior; in some respects it does and in some it does not. What is remarkable is that rates of sexual behavior considered to be unsafe are no higher than other countries with far lower rates of HIV, countries in Africa and elsewhere. People in Lesotho are at higher risk than almost anywhere else in the world, but no research has shown why this is so.
The study authors also claim that their findings provide a 'concrete basis' for male circumcision. Well, there are countries where male circumcision status may be correlated with HIV prevalence. In some countries, circumcision appears to be protective, for example, Kenya. But Lesotho is one of the countries where the opposite may be the case. Of course, these correlations may point to something else entirely.
About half of all men in Lesotho are circumcised. But while uncircumcised men are a bit more likely to be HIV positive in some age groups, overall, circumcised men are far more likely to be HIV positive. It could be argued that many circumcised men were infected before being circumcised, but there is then the problem of explaining how they were infected with a virus that can have as little as a 1 in one thousand chance of being transmitted during heterosexual intercourse.
I would argue that both the spatial data created by Myong-Hyun Go and Co and the DHS data show that Lesotho has extraordinarily high HIV prevalence figures and both sets of data suggest that a substantial proportion of HIV may be transmitted non-sexually. But the disturbing thing about each set of data is that neither really shed light on the possible extent of non-sexual and sexual transmission. Without knowing this, the way forward is no clearer than it was before the data was collected.
And that's pretty much how the HIV industry works. The view that HIV is mainly transmitted heterosexually in African countries is sometimes called the 'behavioral paradigm'. And it is not really amenable to evidence, for or against. It is, let's be frank, a prejudice. So it is worth looking a bit more closely at some figures for HIV in Lesotho.
The study in question uses data from the 2004 Lesotho Demographic and Health Survey (DHS), but as the 2009 survey is available, I'll be referring to it instead. After all, the authors expect their work to influence health policy, so it would need to apply equally to both early and later data.
In common with many other African countries, women usually report very low levels of multiple sex partners, with less than 10% having more than one partner in the previous 12 months and a mean number of lifetime partners never exceeding 3. And while HIV prevalence differs a lot spatially, levels of multiple sex partners and mean number of lifetime partners does not.
Men usually report far higher levels of multiple partnership, double or even triple the levels for women. Their mean number of sexual partners is also up to three times higher. Such differences are equally pronounced among young people. Yet far more women than men are HIV positive in most age groups and in most areas. This is also the case in other African countries.
HIV prevalence by sexual behavior figures show that orthodox thinking about age at first intercourse is in need of review. For women, those who first have sex at less than 16 years old have the same HIV prevalence as those who start at 20 years or over. For men, prevalence actually rises with age, with those starting early having lower prevalence. Prevalence for men and women who use condoms is about the same as it is for those who don't.
But the most remarkable thing about the figures is not that HIV prevalence does or does not correlate with sexual behavior; in some respects it does and in some it does not. What is remarkable is that rates of sexual behavior considered to be unsafe are no higher than other countries with far lower rates of HIV, countries in Africa and elsewhere. People in Lesotho are at higher risk than almost anywhere else in the world, but no research has shown why this is so.
The study authors also claim that their findings provide a 'concrete basis' for male circumcision. Well, there are countries where male circumcision status may be correlated with HIV prevalence. In some countries, circumcision appears to be protective, for example, Kenya. But Lesotho is one of the countries where the opposite may be the case. Of course, these correlations may point to something else entirely.
About half of all men in Lesotho are circumcised. But while uncircumcised men are a bit more likely to be HIV positive in some age groups, overall, circumcised men are far more likely to be HIV positive. It could be argued that many circumcised men were infected before being circumcised, but there is then the problem of explaining how they were infected with a virus that can have as little as a 1 in one thousand chance of being transmitted during heterosexual intercourse.
I would argue that both the spatial data created by Myong-Hyun Go and Co and the DHS data show that Lesotho has extraordinarily high HIV prevalence figures and both sets of data suggest that a substantial proportion of HIV may be transmitted non-sexually. But the disturbing thing about each set of data is that neither really shed light on the possible extent of non-sexual and sexual transmission. Without knowing this, the way forward is no clearer than it was before the data was collected.
Monday, March 21, 2011
GPS Data Analysis Upholds Stork Theory of Where Babies Come From
A story is told about a grumpy conductor who said to a cellist (I'm paraphrasing): 'You have between your legs one of the most sensitive instruments known to man, and all you can do is scratch it'. The story comes to mind sometimes when reading the latest findings about HIV epidemics.
Many researchers come up with great data, data that should change the way that HIV prevention programs are targeted. A lot of recent data, and even some not so recent, clearly shows that HIV transmission is not nearly as closely related to sexual transmission as has been assumed so far. But this never seems to have any influence on prevention programs.
UNAIDS and the HIV industry in general take it as read that 80% of HIV transmission in African countries is a result of heterosexual sex. They claim that almost all of the remaining 20% is accounted for by mother to child transmission. This leaves very little for intravenous drug use, men who have sex with men and various forms of non-sexual transmission, such as unsafe healthcare.
A recent piece of research by Myong-Hyun Go, B Coburn, J Okano and S Blower uses GPS coordinates to depict HIV clusters or hot-spots in Lesotho. Lesotho has one some of the highest HIV prevalence figures in the world. They range from 8.5-46.6% for women and 4.1-39% for men.
Remarkably, the hot-spots for high female prevalence do not overlap with those for males very much. Those for females are mainly located in two lowland urban centres, the most heavily populated areas in the country. Those for males are mainly located in two less heavily populated mountainous areas, quite distant from the urban centres.
The research also finds that travel between most parts of Lesotho is not too efficient. Even travel between areas of high female prevalence and high male prevalence, according to the maps provided, could be quite challenging. These findings are referred to as 'spatial heterogeneity', which sounds rather quaint, under the circumstances.
Do most of the inhabitants of one of the poorest countries in the world expend most of their time and income on travelling to and from different parts of the country for the sole purpose of having sex, with as many different partners as possible, if official HIV lore is to be believed?
I think many people whose minds are relatively unbiased, especially by said official HIV lore, might question the 'behavioral paradigm', the view that almost all HIV is heterosexually transmitted in African countries. There must be something else to these incredible rates of transmission.
Not only must people be having immense numbers of sexual experiences, with immense numbers of people, but if the heterosexual sex theory is true, there must also be something else accounting for the increased susceptibility of this population.
After all, HIV prevalence among sex workers in India is only about 7% and the disease, according to the official story, is something of an occupational hazard for them. National prevalence in Kenya, Tanzania and Uganda is around 7% or less, which is itself shocking when compared to the figure for India.
But even if we embrace the extreme prejudices of UNAIDS and their accomplices, we must still wonder what it is about the Basotho people that accounts for almost unprecedented rates of transmission (and, of course, their superhuman feats of mobility and sexual prowess).
The researchers, however, don't even raise such questions. They merely conclude that prevention programs must be gender specific ones, such as circumcision for men and microbicides for women.
Even if it is true that most transmission is through heterosexual sex, these interventions will have only a relatively small impact, if any. Neither intervention has been shown to reduce transmission very much outside of some highly questionable trials.
But the data screams out for thorough investigation of how HIV could be transmitted heterosexually when so many HIV positive men and women live so far from each other. There is also an urgent need to find out if there is some additional factor that could explain how a virus that is difficult to transmit sexually affects such an enormous number of people. And it would be a further disgrace to the HIV industry if it just lets this data go by without it having any influence on global HIV prevention policy.
Many researchers come up with great data, data that should change the way that HIV prevention programs are targeted. A lot of recent data, and even some not so recent, clearly shows that HIV transmission is not nearly as closely related to sexual transmission as has been assumed so far. But this never seems to have any influence on prevention programs.
UNAIDS and the HIV industry in general take it as read that 80% of HIV transmission in African countries is a result of heterosexual sex. They claim that almost all of the remaining 20% is accounted for by mother to child transmission. This leaves very little for intravenous drug use, men who have sex with men and various forms of non-sexual transmission, such as unsafe healthcare.
A recent piece of research by Myong-Hyun Go, B Coburn, J Okano and S Blower uses GPS coordinates to depict HIV clusters or hot-spots in Lesotho. Lesotho has one some of the highest HIV prevalence figures in the world. They range from 8.5-46.6% for women and 4.1-39% for men.
Remarkably, the hot-spots for high female prevalence do not overlap with those for males very much. Those for females are mainly located in two lowland urban centres, the most heavily populated areas in the country. Those for males are mainly located in two less heavily populated mountainous areas, quite distant from the urban centres.
The research also finds that travel between most parts of Lesotho is not too efficient. Even travel between areas of high female prevalence and high male prevalence, according to the maps provided, could be quite challenging. These findings are referred to as 'spatial heterogeneity', which sounds rather quaint, under the circumstances.
Do most of the inhabitants of one of the poorest countries in the world expend most of their time and income on travelling to and from different parts of the country for the sole purpose of having sex, with as many different partners as possible, if official HIV lore is to be believed?
I think many people whose minds are relatively unbiased, especially by said official HIV lore, might question the 'behavioral paradigm', the view that almost all HIV is heterosexually transmitted in African countries. There must be something else to these incredible rates of transmission.
Not only must people be having immense numbers of sexual experiences, with immense numbers of people, but if the heterosexual sex theory is true, there must also be something else accounting for the increased susceptibility of this population.
After all, HIV prevalence among sex workers in India is only about 7% and the disease, according to the official story, is something of an occupational hazard for them. National prevalence in Kenya, Tanzania and Uganda is around 7% or less, which is itself shocking when compared to the figure for India.
But even if we embrace the extreme prejudices of UNAIDS and their accomplices, we must still wonder what it is about the Basotho people that accounts for almost unprecedented rates of transmission (and, of course, their superhuman feats of mobility and sexual prowess).
The researchers, however, don't even raise such questions. They merely conclude that prevention programs must be gender specific ones, such as circumcision for men and microbicides for women.
Even if it is true that most transmission is through heterosexual sex, these interventions will have only a relatively small impact, if any. Neither intervention has been shown to reduce transmission very much outside of some highly questionable trials.
But the data screams out for thorough investigation of how HIV could be transmitted heterosexually when so many HIV positive men and women live so far from each other. There is also an urgent need to find out if there is some additional factor that could explain how a virus that is difficult to transmit sexually affects such an enormous number of people. And it would be a further disgrace to the HIV industry if it just lets this data go by without it having any influence on global HIV prevention policy.
Thursday, March 17, 2011
Are Racism and Sexism Lessened by Being Passive-Aggressively Pursued?
Following yesterday's blog post I had a brief email conversation with Dr David Gisselquist during which he pointed out that higher levels of education, to some extent, and greater wealth, to a large extent, tend to correlate with higher HIV prevalence in African countries. Researchers are not sure what to make of these correlations, though they are well attested.
Anyhow, neither of us find the World Bank claims particularly credible and they seem to go hand in hand with a purely sexual view of African HIV transmission, the so called 'behavioral paradigm'. The view is both racist and sexist. Imagine a similar handing out of money to Western women aimed at influencing their sexual behavior, and particularly their reproductive intentions.
Anyhow, giving girls money and paying their school fees could be expected to result in higher HIV prevalence among the recipients, unless transmission patterns have changed substantially, and only since all previous population based surveys of the last 15 or 20 years have been carried out.
The same article refers briefly to a Tanzanian study, which gave cash incentives to adults who tested negative for certain sexually transmitted infections (STI). But public health experts are well aware that STIs are more than just a reflection of sexual behavior. They also reflect broaderhealth conditions in a country, that's why certain STI rates are very high in some US and other Western populations.
The idea of handing out money to people in an attempt to influence their behavior or lifestyle is not confined to sexual behavior, nor even to young people in developing countries. Money has also been used to persuade women (and some men) to use birth control of some kind, or even to be sterilized, because an institution called 'Project Prevention' has wished to intervene for one of several reasons.
Project Prevention aims at female drug users in Western countries, because they are said to play a significant part in HIV transmission there. But it is HIV positive women who are targeted in Africa (Kenya, specifically). The aim is not really prevention because if HIV transmission had been prevented in the first place, there would be no need to prevent the possible vertical transmission of HIV from the mother to their children. And Project Prevention aim to eliminate the child, hence, no prevention if they achieve that aim.
Ironically, one of the favored methods of birth control employed by Project Prevention is the intrauterine device (IUD). If Project Prevention gave a damn about the safety of women at all, they would check out the sort of conditions found in health facilities in Kenya and other high HIV prevalence countries. Getting an IUD inserted in Kenya will carry many risks, including the risk of infection with diseases such as HIV.
And that's only if things go reasonably well. If women have any future problems with an IUD they will face further, similar risks and perhaps some additional ones. Many will continue to have little access to adequate health care after Project Prevention have handed over their few dollars a head and, in common with most African women, will probably just have to put up with whatever injury that results.
Whether it is right or even effective to hand over a few dollars to influence people's behavior is one thing. And there is a lot of discussion about these questions. But even if the answer is that it is both right and effective, it will not work, because HIV is not, and never has been, purely a matter of individual behavior, sexual or otherwise.
Some commentators are correct in referring to Project Prevention's agenda as pure eugenics or 'racial hygiene'. But then, so is the bulk of prevention work carried out by the big players in HIV prevention, including Population Services International, Family Health International, The Futures Group International, the Guttemacher Institute, the Rockefeller Foundation, the Gates Foundation and many others.
Most of the billions contributed to the multi-billion dollar HIV industry has gone to treating HIV positive people. But most of the considerable fraction that has gone into prevention, very unsuccessful too, has been frittered away on trying to influence people's sexual and reproductive behavior. Project Prevention's strategy is extreme, but that's really only a matter of degree.
The various commentators abhorring the work of Project Prevention are all rightly concerned about preventing HIV transmission from mothers to their babies and they are also right in pointing out that this is a well developed and relatively successful area of HIV prevention. The problem is that too few women who are about to become pregnant, or are already pregnant, or even who have just given birth, are in any way protected from HIV infection.
It is the very assumption that HIV is almost always sexually transmitted that results in the stigma that these commentators also abhor. Project Prevention is contributing to the stigma, but so are these well-meaning critics. If the HIV industry could lose its obsession with the sexual and reproductive behavior of people in developing countries, they would be able to prevent HIV transmission that is clearly not coming from heterosexual sex.
HIV in poor countries is commonly associated with pregnancy. But this does not mean it is therefore also caused by sexual behavior. Many women are infected when they are in the later stages of pregnancy, or even after they give birth. And this is often the case when they have a HIV negative partner and they have only had sex with this HIV negative partner. At least some of these women were infected non-sexually.
Some HIV negative women have HIV positive babies and, despite the excuses of UNAIDS and others, all of these babies were infected non-sexually, probably through unsafe healthcare of some kind. HIV positive babies can even infect their mothers during breastfeeding.
Project Prevention may be racist and sexist bullies, who prey on vulnerable people in developing countries. But what they are doing is not that different from the more passive aggressive forms of racism and sexism that constitute global HIV prevention policy. HIV is not just another sexually transmitted infection, though it may sometimes be transmitted sexually. Eradicating the virus depends on accepting that and investigating the extent to which it is transmitted sexually and non-sexually.
Anyhow, neither of us find the World Bank claims particularly credible and they seem to go hand in hand with a purely sexual view of African HIV transmission, the so called 'behavioral paradigm'. The view is both racist and sexist. Imagine a similar handing out of money to Western women aimed at influencing their sexual behavior, and particularly their reproductive intentions.
Anyhow, giving girls money and paying their school fees could be expected to result in higher HIV prevalence among the recipients, unless transmission patterns have changed substantially, and only since all previous population based surveys of the last 15 or 20 years have been carried out.
The same article refers briefly to a Tanzanian study, which gave cash incentives to adults who tested negative for certain sexually transmitted infections (STI). But public health experts are well aware that STIs are more than just a reflection of sexual behavior. They also reflect broaderhealth conditions in a country, that's why certain STI rates are very high in some US and other Western populations.
The idea of handing out money to people in an attempt to influence their behavior or lifestyle is not confined to sexual behavior, nor even to young people in developing countries. Money has also been used to persuade women (and some men) to use birth control of some kind, or even to be sterilized, because an institution called 'Project Prevention' has wished to intervene for one of several reasons.
Project Prevention aims at female drug users in Western countries, because they are said to play a significant part in HIV transmission there. But it is HIV positive women who are targeted in Africa (Kenya, specifically). The aim is not really prevention because if HIV transmission had been prevented in the first place, there would be no need to prevent the possible vertical transmission of HIV from the mother to their children. And Project Prevention aim to eliminate the child, hence, no prevention if they achieve that aim.
Ironically, one of the favored methods of birth control employed by Project Prevention is the intrauterine device (IUD). If Project Prevention gave a damn about the safety of women at all, they would check out the sort of conditions found in health facilities in Kenya and other high HIV prevalence countries. Getting an IUD inserted in Kenya will carry many risks, including the risk of infection with diseases such as HIV.
And that's only if things go reasonably well. If women have any future problems with an IUD they will face further, similar risks and perhaps some additional ones. Many will continue to have little access to adequate health care after Project Prevention have handed over their few dollars a head and, in common with most African women, will probably just have to put up with whatever injury that results.
Whether it is right or even effective to hand over a few dollars to influence people's behavior is one thing. And there is a lot of discussion about these questions. But even if the answer is that it is both right and effective, it will not work, because HIV is not, and never has been, purely a matter of individual behavior, sexual or otherwise.
Some commentators are correct in referring to Project Prevention's agenda as pure eugenics or 'racial hygiene'. But then, so is the bulk of prevention work carried out by the big players in HIV prevention, including Population Services International, Family Health International, The Futures Group International, the Guttemacher Institute, the Rockefeller Foundation, the Gates Foundation and many others.
Most of the billions contributed to the multi-billion dollar HIV industry has gone to treating HIV positive people. But most of the considerable fraction that has gone into prevention, very unsuccessful too, has been frittered away on trying to influence people's sexual and reproductive behavior. Project Prevention's strategy is extreme, but that's really only a matter of degree.
The various commentators abhorring the work of Project Prevention are all rightly concerned about preventing HIV transmission from mothers to their babies and they are also right in pointing out that this is a well developed and relatively successful area of HIV prevention. The problem is that too few women who are about to become pregnant, or are already pregnant, or even who have just given birth, are in any way protected from HIV infection.
It is the very assumption that HIV is almost always sexually transmitted that results in the stigma that these commentators also abhor. Project Prevention is contributing to the stigma, but so are these well-meaning critics. If the HIV industry could lose its obsession with the sexual and reproductive behavior of people in developing countries, they would be able to prevent HIV transmission that is clearly not coming from heterosexual sex.
HIV in poor countries is commonly associated with pregnancy. But this does not mean it is therefore also caused by sexual behavior. Many women are infected when they are in the later stages of pregnancy, or even after they give birth. And this is often the case when they have a HIV negative partner and they have only had sex with this HIV negative partner. At least some of these women were infected non-sexually.
Some HIV negative women have HIV positive babies and, despite the excuses of UNAIDS and others, all of these babies were infected non-sexually, probably through unsafe healthcare of some kind. HIV positive babies can even infect their mothers during breastfeeding.
Project Prevention may be racist and sexist bullies, who prey on vulnerable people in developing countries. But what they are doing is not that different from the more passive aggressive forms of racism and sexism that constitute global HIV prevention policy. HIV is not just another sexually transmitted infection, though it may sometimes be transmitted sexually. Eradicating the virus depends on accepting that and investigating the extent to which it is transmitted sexually and non-sexually.
Sunday, March 13, 2011
Africans Slowly Start to Question the Popular View of 'African' Sexuality
It's nothing new for a Kenyan minister to opt for foreign medical services rather than settle for the best their own country has to offer. Never mind that non-whites in the US currently get the worst medical services their country has to offer, if they get anything at all. Kenya has some high quality, private facilities, but the country's political elite are not tempted.
However, when the Minister for Medical Services, Professor Anyang' Nyong'o, heads to the US for prostate work, people may do well to sit up and take notice. Does the Minister know something about Kenyan health services that leads to those in the best position to judge their quality choosing to head off elsewhere? Of course, he is hardly going to face the sort of hazards faced by non-white Americans, but there surely must be something available in Kenya for those able to pay, or for those who don't have to pay?
Well, in early October of last year, the same minister pointed out that there are many problems with health care provision in the country. Quite an understatement. I blogged about it at the time and there are a couple of links to some further information.
But Nyong'o is remarkable in drawing attention also to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. Politicians normally don't even come close to considering this possibility, that at least some HIV transmission in countries with appalling health services may result from unsafe health care practices.
The closest I have heard has come from former South African President Thabo Mbeki, who pointed out that Africans face numerous health risks that could just as easily explain what the rest of the world calls the HIV epidemic. Mbeki infamously went a lot further than that and refused to accept that there was a HIV epidemic. He made the biggest blunder possible, despite his valuable insights into the plight of Africans and other developing peoples.
But people like Mbeki, and even Nyong'o, are shedding more light on the drivers of HIV than whole teams of highly qualified scientists from the Johns Hopkins School of Medicine and various other elite academic institutions. There are some Africans who sense that the deeply racist explanation of HIV being driven by some notional African sexuality is not going to help eradicate the virus.
Nyong'o also raises other interesting points, such as the lower quality of health care found in rural areas, compared to urban areas. But he doesn't go far enough. Most rural areas have no health care facilities whatsoever, the majority of facilities being located close to or in urban centres, or at least close to surfaced roads, another thing that is in short supply in Kenya.
And he could have gone further still: in areas of Kenya where access to health facilities is lowest, HIV prevalence is also lowest. Yet, it is clear that people don't have less sex, or less unprotected sex, in these areas. In the North Eastern province, where health and other social services are lowest, birth rates are highest, early marriages are most common, female genital mutilation is most common, intergenerational marriages are most common, etc.
Mbeki was wrong in concluding that HIV affects the poorest disproportionately; it affects those who are just rich enough to access what are very poor health services. Of course, many such people are poor and suffer from numerous other health hazards, but the richest of the poor suffer the highest rates of HIV. And that probably means that even the best health facilities are not too reliable and Nyong'o is better off taking his chances with the health facilities of a country that would normally discriminate against him.
However, when the Minister for Medical Services, Professor Anyang' Nyong'o, heads to the US for prostate work, people may do well to sit up and take notice. Does the Minister know something about Kenyan health services that leads to those in the best position to judge their quality choosing to head off elsewhere? Of course, he is hardly going to face the sort of hazards faced by non-white Americans, but there surely must be something available in Kenya for those able to pay, or for those who don't have to pay?
Well, in early October of last year, the same minister pointed out that there are many problems with health care provision in the country. Quite an understatement. I blogged about it at the time and there are a couple of links to some further information.
But Nyong'o is remarkable in drawing attention also to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. Politicians normally don't even come close to considering this possibility, that at least some HIV transmission in countries with appalling health services may result from unsafe health care practices.
The closest I have heard has come from former South African President Thabo Mbeki, who pointed out that Africans face numerous health risks that could just as easily explain what the rest of the world calls the HIV epidemic. Mbeki infamously went a lot further than that and refused to accept that there was a HIV epidemic. He made the biggest blunder possible, despite his valuable insights into the plight of Africans and other developing peoples.
But people like Mbeki, and even Nyong'o, are shedding more light on the drivers of HIV than whole teams of highly qualified scientists from the Johns Hopkins School of Medicine and various other elite academic institutions. There are some Africans who sense that the deeply racist explanation of HIV being driven by some notional African sexuality is not going to help eradicate the virus.
Nyong'o also raises other interesting points, such as the lower quality of health care found in rural areas, compared to urban areas. But he doesn't go far enough. Most rural areas have no health care facilities whatsoever, the majority of facilities being located close to or in urban centres, or at least close to surfaced roads, another thing that is in short supply in Kenya.
And he could have gone further still: in areas of Kenya where access to health facilities is lowest, HIV prevalence is also lowest. Yet, it is clear that people don't have less sex, or less unprotected sex, in these areas. In the North Eastern province, where health and other social services are lowest, birth rates are highest, early marriages are most common, female genital mutilation is most common, intergenerational marriages are most common, etc.
Mbeki was wrong in concluding that HIV affects the poorest disproportionately; it affects those who are just rich enough to access what are very poor health services. Of course, many such people are poor and suffer from numerous other health hazards, but the richest of the poor suffer the highest rates of HIV. And that probably means that even the best health facilities are not too reliable and Nyong'o is better off taking his chances with the health facilities of a country that would normally discriminate against him.
Saturday, March 12, 2011
Why Poor Access to Health Facilities May Save Lives in Africa
"Hospital Births Still Unpopular" in Ethiopia, writes IRIN, the UN development news agency. But is this a good or bad thing? Ethiopia has never managed to provide the majority of its inhabitants with health services. Yet HIV prevalence, like in many other countries with low health service usage, is relatively low, at just over 2%.
In South Africa (and several other Southern African countries with high health service usage), HIV prevalence is staggeringly high. These are not just two countries where HIV prevalence and health service usage happen to be negatively correlated, there are many others. Zimbabwe has had high health service usage at times in its history, as have Swaziland, Botswana and Zambia, all in the top ten for HIV prevalence.
Where health services are of high quality, things are quite different. Take Cuba, for example, which has some of the best health indicators in the world and the lowest HIV prevalence in the Carribean. Similar remarks apply to many other Western countries and even a few developing countries.
Even the US has good health services for those who can afford them. But sadly, those who can't afford the best experience the highest HIV rates in the country. Most of them also happen to be non-white. And before you ask, yes, HIV and other viruses can be transmitted in US health services too. Do you think that doctor specializing in late abortions had any more respect for adults than for children?
To conclude that countries need fewer health services would be crazy, though it is the direct aim of the World Bank and the International Monetary Fund, through their structural adjustment programs, or whatever they call them now. And it is the indirect aim of the WHO and UNAIDS, through their insistence that grossly disproportionate amounts of health spending goes to HIV.
Despite the barbaric health agenda of global economic health institutions, African countries, like all countries, need good health services. They also need decent levels of education, good infrastructure, economic and employment opportunities, in other words, a future. But that is what they have been denied for many decades. Human rights that have been denied many countries for so long don't appear to be any more forthcoming now that they were in the past, either.
The argument that HIV spending puts all other health spending in the shade is not even the most important issue here. The most important issue is that the billions of dollars that have gone into HIV so far have done little to reduce transmission enough to see the virus being eradicated any time soon.
Not that much of the money has been spent on prevention anyway, and what has been spent was frittered away on pointless exercises, which will probably continue for some time, because the 'experts' simply don't have any idea what else to do. They don't know how to reduce HIV transmission, or they don't wish to suggest that the health industry itself may be part of the problem.
You could argue that the multi-billion dollar per annum global HIV industry is run by a bunch of buffoons and you'd probably have some supporters. Like any professional group, there are buffoons. But there are also people who are the best in their field. And then it sounds as if things get done or remain undone because that's what the whole lot of them, buffoon or otherwise, want.
For example, a bunch of people of some description found that 'only' 1.4% of HIV positive children had HIV negative mothers. They speculated about these children being infected by contaminated breast milk, which is a possible explanation. But they hesitate to conclude that infants and mothers may be at risk of infection through unsafe health care practices.
This is surprising because the same researchers found that 47% of instruments were contaminated with blood, many of these instruments being used for invasive procedures. They also found that many of the HIV positive children with HIV negative mothers were breastfed by a non-biological mother. So there are several possible sources of non-sexual HIV transmission, but this research is just scratching the surface.
HIV negative mothers can be infected by their babies if their babies are infected nosocomially. This has been demonstrated many times, especially in Romania, which experienced a massive outbreak of nosocomially transmitted HIV, one of the biggest ever brought to light.
Also, both mothers and babies can be independently infected, though various routes. The fact that many mother and baby pairs were both infected does not tell you how either of them became infected. Researchers might need to do a bit of work to establish that.
As for the HIV positive women, with or without HIV positive babies, how were they infected? Were their partners tested? Partners tend not to be routinely contacted and tested and it seems they were not in this instance, or perhaps the authors didn't think it important enough to comment on. Half of all HIV positive women in African countries have HIV negative partners. How did they become infected?
But one of the most striking aspects of HIV testing in pregnant women is how many of them seroconvert very late during pregnancy or even in the months after giving birth. This suggests that many of them were also infected after they would have known they were pregnant or even just after they had given birth.
I'm not an expert in these matters but many women have told me they do not tend to have that much sexual activity during late pregnancy or in the months just after giving birth. And they certainly don't see this as a good time to engage in unprotected sex with people who are not their main partner. Why not cast the net a little wider and look at the most likely modes of transmission, non-sexual modes, rather than the least likely mode, heterosexual transmission?
I'm looking for what researchers don't talk about, what they don't find, usually because they are not looking. Why are researchers not contacting and testing partners as a matter of routine? Why are they not following up HIV seroconversions which are very unlikely to have resulted from sexual transmission? They need to put their anti-African and anti-woman prejudices aside and start investigating. African hospitals are clearly dangerous places.
In South Africa (and several other Southern African countries with high health service usage), HIV prevalence is staggeringly high. These are not just two countries where HIV prevalence and health service usage happen to be negatively correlated, there are many others. Zimbabwe has had high health service usage at times in its history, as have Swaziland, Botswana and Zambia, all in the top ten for HIV prevalence.
Where health services are of high quality, things are quite different. Take Cuba, for example, which has some of the best health indicators in the world and the lowest HIV prevalence in the Carribean. Similar remarks apply to many other Western countries and even a few developing countries.
Even the US has good health services for those who can afford them. But sadly, those who can't afford the best experience the highest HIV rates in the country. Most of them also happen to be non-white. And before you ask, yes, HIV and other viruses can be transmitted in US health services too. Do you think that doctor specializing in late abortions had any more respect for adults than for children?
To conclude that countries need fewer health services would be crazy, though it is the direct aim of the World Bank and the International Monetary Fund, through their structural adjustment programs, or whatever they call them now. And it is the indirect aim of the WHO and UNAIDS, through their insistence that grossly disproportionate amounts of health spending goes to HIV.
Despite the barbaric health agenda of global economic health institutions, African countries, like all countries, need good health services. They also need decent levels of education, good infrastructure, economic and employment opportunities, in other words, a future. But that is what they have been denied for many decades. Human rights that have been denied many countries for so long don't appear to be any more forthcoming now that they were in the past, either.
The argument that HIV spending puts all other health spending in the shade is not even the most important issue here. The most important issue is that the billions of dollars that have gone into HIV so far have done little to reduce transmission enough to see the virus being eradicated any time soon.
Not that much of the money has been spent on prevention anyway, and what has been spent was frittered away on pointless exercises, which will probably continue for some time, because the 'experts' simply don't have any idea what else to do. They don't know how to reduce HIV transmission, or they don't wish to suggest that the health industry itself may be part of the problem.
You could argue that the multi-billion dollar per annum global HIV industry is run by a bunch of buffoons and you'd probably have some supporters. Like any professional group, there are buffoons. But there are also people who are the best in their field. And then it sounds as if things get done or remain undone because that's what the whole lot of them, buffoon or otherwise, want.
For example, a bunch of people of some description found that 'only' 1.4% of HIV positive children had HIV negative mothers. They speculated about these children being infected by contaminated breast milk, which is a possible explanation. But they hesitate to conclude that infants and mothers may be at risk of infection through unsafe health care practices.
This is surprising because the same researchers found that 47% of instruments were contaminated with blood, many of these instruments being used for invasive procedures. They also found that many of the HIV positive children with HIV negative mothers were breastfed by a non-biological mother. So there are several possible sources of non-sexual HIV transmission, but this research is just scratching the surface.
HIV negative mothers can be infected by their babies if their babies are infected nosocomially. This has been demonstrated many times, especially in Romania, which experienced a massive outbreak of nosocomially transmitted HIV, one of the biggest ever brought to light.
Also, both mothers and babies can be independently infected, though various routes. The fact that many mother and baby pairs were both infected does not tell you how either of them became infected. Researchers might need to do a bit of work to establish that.
As for the HIV positive women, with or without HIV positive babies, how were they infected? Were their partners tested? Partners tend not to be routinely contacted and tested and it seems they were not in this instance, or perhaps the authors didn't think it important enough to comment on. Half of all HIV positive women in African countries have HIV negative partners. How did they become infected?
But one of the most striking aspects of HIV testing in pregnant women is how many of them seroconvert very late during pregnancy or even in the months after giving birth. This suggests that many of them were also infected after they would have known they were pregnant or even just after they had given birth.
I'm not an expert in these matters but many women have told me they do not tend to have that much sexual activity during late pregnancy or in the months just after giving birth. And they certainly don't see this as a good time to engage in unprotected sex with people who are not their main partner. Why not cast the net a little wider and look at the most likely modes of transmission, non-sexual modes, rather than the least likely mode, heterosexual transmission?
I'm looking for what researchers don't talk about, what they don't find, usually because they are not looking. Why are researchers not contacting and testing partners as a matter of routine? Why are they not following up HIV seroconversions which are very unlikely to have resulted from sexual transmission? They need to put their anti-African and anti-woman prejudices aside and start investigating. African hospitals are clearly dangerous places.
Friday, March 11, 2011
You Can't Reduce Stigma By Replacing One Lie With Another
I have just spent the last couple of weeks in Ireland and the UK visiting relatives and friends. I'm always struck by how distorted a picture of HIV people there have. Most people in Western countries have an education beyond anything that most Africans will ever receive. But what the public get to hear about massive industrial interests is as skewed there as it is here in Africa.
There are different distortions involved, though. Low prevalence, Western countries are usually said to have 'concentrated' epidemics; most of those infected belong to subgroups in the population, such as men who have sex with men (MSM) and injection drug users (IDU). Because the majority of people in these groups happen to be men, far more men than women are infected.
High prevalence epidemics in African (and a few other) countries are called 'generalized', because the majority of people infected do not belong to any specific 'risk groups'. In fact, in generalized epidemics, the majority of people are heterosexual and more women, often far more women, are infected.
There are two other ways of categorizing HIV epidemics. There are also those referred to as low, though still generalized, and those referred to as hyperendemic. But in reality these are just a matter of degree. The most significant difference between epidemics is between those where the main risk factor is said to be penile-vaginal sex and those where there are clearly other risk factors.
That makes it sound as if there are really two different viruses. People are often rightly puzzled about how a virus that is difficult to transmit via penile-vaginal sex is almost always transmitted in that way in certain, high (and even some medium and low) prevalence countries. UNAIDS deals with that puzzlement by building up a picture of a highly aggressive and totally unrealistic level of sexual behavior that is said only to exist in Africa.
And many are happy to accept that Africans have extraordinary amounts of sex with eye-watering numbers of partners, and probably even that they do all sorts of things that non-Africans wouldn't do.
Such a racist and sexist view of HIV transmission is endorsed by academic, religious and political institutions and a whole industry has built up around it. Media participation in the distortion has also been vital and media organizations have been falling over themselves to bellow out the latest 'discovery' in the field.
There are those who ask questions about certain aspects of the orthodox account of HIV transmission. If they are laypeople, they are usually ignored or, at best, patted on the head and told the 'facts of life' about HIV. If they are professionals they are branded as denialists and publicly humiliated.
I happened to meet a journalist last week who has questioned the orthodox view, at least as it relates to one small Western country. He has worked with injection drug users, men who have sex with men and commercial sex workers. He has long been aware that the risk of being infected with HIV is small unless you belong to one of these groups. He is even aware that the risk to commercial sex workers is low unless they are also IDUs.
He hasn't been publicly disgraced, but he has been told to be more careful what he says. The reason he has been told to be careful may be valid enough: it upsets the gay community. But gay communities in every country need to be aware that unprotected anal sex and injecting drug use are the two most common means of transmitting HIV in most Western countries.
And heterosexuals in every country need to be able to evaluate their risk. They can not do this if it is stated or implied that the risk they face is as high as that of anyone else; it isn't. If HIV was mainly transmitted by heterosexual sex there would be no pandemic. In fact, the virus might never have gone beyond a few isolated cases in a small area in Africa.
If the HIV pandemic can not be explained by penile-vaginal sex, how can it be explained? Well, we know that HIV can be transmitted far more efficiently by contaminated blood and other bodily fluids than by sex. Most forms of health care transmission may have been eliminated in Western countries, but some may still be common in poorer countries.
There are really only two kinds of HIV epidemic; those where most people infected are users of health (and possibly cosmetic) facilities and those where most people infected are MSM and IDUs. People are not infected because they are in some way less innocent or less worthy individuals. Such a view is sinister and pervasive, but without foundation of any kind.
HIV is difficult to transmit via penile-vaginal sex, but it is easy to transmit via contaminated bodily fluids, including blood. That blood and anal mucus are involved in anal sex, and often in HIV transmission, is not to say that HIV a 'gay disease'. It is not tantamount to saying that gay people are bad or that gay sex is bad. After all, heterosexuals have anal sex too and the risk is just as high for them.
But if HIV transmission is to be reduced and eventually eradicated, people need to be clear about exactly what risks they face. And when those risks are health care related risks they don't need lectures about safe sex, condoms, number of partners, etc. If gay people are worried about prejudice, this is completely understandable.
But making out that HIV is commonly transmitted through penile-vaginal sex when that is not the case leads to prejudice too. As a consequence of this distortion, many people are infected non-sexually because most are unaware that such risks exist. These millions of people who are avoidably infected are also stigmatized because non-sexual transmission is said to be so unlikely. Let's not replace one distortion with another.
There are different distortions involved, though. Low prevalence, Western countries are usually said to have 'concentrated' epidemics; most of those infected belong to subgroups in the population, such as men who have sex with men (MSM) and injection drug users (IDU). Because the majority of people in these groups happen to be men, far more men than women are infected.
High prevalence epidemics in African (and a few other) countries are called 'generalized', because the majority of people infected do not belong to any specific 'risk groups'. In fact, in generalized epidemics, the majority of people are heterosexual and more women, often far more women, are infected.
There are two other ways of categorizing HIV epidemics. There are also those referred to as low, though still generalized, and those referred to as hyperendemic. But in reality these are just a matter of degree. The most significant difference between epidemics is between those where the main risk factor is said to be penile-vaginal sex and those where there are clearly other risk factors.
That makes it sound as if there are really two different viruses. People are often rightly puzzled about how a virus that is difficult to transmit via penile-vaginal sex is almost always transmitted in that way in certain, high (and even some medium and low) prevalence countries. UNAIDS deals with that puzzlement by building up a picture of a highly aggressive and totally unrealistic level of sexual behavior that is said only to exist in Africa.
And many are happy to accept that Africans have extraordinary amounts of sex with eye-watering numbers of partners, and probably even that they do all sorts of things that non-Africans wouldn't do.
Such a racist and sexist view of HIV transmission is endorsed by academic, religious and political institutions and a whole industry has built up around it. Media participation in the distortion has also been vital and media organizations have been falling over themselves to bellow out the latest 'discovery' in the field.
There are those who ask questions about certain aspects of the orthodox account of HIV transmission. If they are laypeople, they are usually ignored or, at best, patted on the head and told the 'facts of life' about HIV. If they are professionals they are branded as denialists and publicly humiliated.
I happened to meet a journalist last week who has questioned the orthodox view, at least as it relates to one small Western country. He has worked with injection drug users, men who have sex with men and commercial sex workers. He has long been aware that the risk of being infected with HIV is small unless you belong to one of these groups. He is even aware that the risk to commercial sex workers is low unless they are also IDUs.
He hasn't been publicly disgraced, but he has been told to be more careful what he says. The reason he has been told to be careful may be valid enough: it upsets the gay community. But gay communities in every country need to be aware that unprotected anal sex and injecting drug use are the two most common means of transmitting HIV in most Western countries.
And heterosexuals in every country need to be able to evaluate their risk. They can not do this if it is stated or implied that the risk they face is as high as that of anyone else; it isn't. If HIV was mainly transmitted by heterosexual sex there would be no pandemic. In fact, the virus might never have gone beyond a few isolated cases in a small area in Africa.
If the HIV pandemic can not be explained by penile-vaginal sex, how can it be explained? Well, we know that HIV can be transmitted far more efficiently by contaminated blood and other bodily fluids than by sex. Most forms of health care transmission may have been eliminated in Western countries, but some may still be common in poorer countries.
There are really only two kinds of HIV epidemic; those where most people infected are users of health (and possibly cosmetic) facilities and those where most people infected are MSM and IDUs. People are not infected because they are in some way less innocent or less worthy individuals. Such a view is sinister and pervasive, but without foundation of any kind.
HIV is difficult to transmit via penile-vaginal sex, but it is easy to transmit via contaminated bodily fluids, including blood. That blood and anal mucus are involved in anal sex, and often in HIV transmission, is not to say that HIV a 'gay disease'. It is not tantamount to saying that gay people are bad or that gay sex is bad. After all, heterosexuals have anal sex too and the risk is just as high for them.
But if HIV transmission is to be reduced and eventually eradicated, people need to be clear about exactly what risks they face. And when those risks are health care related risks they don't need lectures about safe sex, condoms, number of partners, etc. If gay people are worried about prejudice, this is completely understandable.
But making out that HIV is commonly transmitted through penile-vaginal sex when that is not the case leads to prejudice too. As a consequence of this distortion, many people are infected non-sexually because most are unaware that such risks exist. These millions of people who are avoidably infected are also stigmatized because non-sexual transmission is said to be so unlikely. Let's not replace one distortion with another.
Tuesday, March 1, 2011
Institutional Sexism and Racism Driving African HIV Epidemics
If you were to consider just two aspects of HIV transmission, firstly, that it is not easily transmitted through heterosexual sex and secondly, that it is easily transmitted by certain non-sexual routes, you might come up with a proto-hypothesis that high prevalence epidemics found in some African countries are not primarily driven by heterosexual sex.
I say 'might' because the HIV industry concludes from the fact that HIV is not easily transmitted through heterosexual sex, that Africans must have extraordinary amounts of sex. Evidence suggests that Africans don't have extraordinary amounts of sex, so the industry further concludes that almost all the sex Africans have is 'unsafe'.
Research has also makes it clear that only some people have a lot of sex, although quite a few Africans (and non-Africans) are reluctant to take precautions and engage in what is considered to be safe sex much of the time. But the majority of Africans, like the majority of non-Africans, just have ordinary amounts of sex, safe or otherwise.
More worryingly, 'safe' sex practices, such as later sexual debut, fewer partners, greater condom use, etc, are often correlated with similar and even higher rates of HIV transmission. Yet still, the HIV industry doesn't conclude that they should put aside their obsession with the sex lives of others and re-examine non-sexual modes of transmission.
Over the years, the industry has come up with one 'explanation' after another as to why very high heterosexual HIV transmission rates are only found in some countries and some parts of some countries, and they are all in Africa. Multiple partnerships was eventually shown not to explain high transmission rates so the concept of concurrency was added in.
But like sex and unsafe sex, evidence showed that only some people engage in concurrent partnerships, sexual partnerships that overlap. Most people don't engage in such partnerships. Also, concurrent partnerships are not exclusive to Africans. They occur everywhere, but without the massive rates of HIV transmission found in some African countries.
It didn't take HIV researchers long to compound the racism of their account of African sexuality with the racist assumption that Africans generally lie about their sexual behavior. Well, some do, as do some non-Africans. But anything that fails to fit the HIV industry picture of African sexuality is discounted as lies.
And the institutional racism itself is compounded by a form of institutional sexism. Women, under the orthodox model, appear to lie a lot more than men. We are told that, not only are they far more promiscuous than men, but they admit to far less promiscuity. The industry 'knows' that they are lying because HIV rates are far higher among women than an assumed greater susceptability could account for.
Few may be surprised to hear that academics, political and religious leaders, professionals of all kinds, journalists and many others are deeply racist and sexist. But I think it would come as a surprise to many to hear that the heterosexual HIV pandemic in African countries is driven by these prejudices.
If Africans don't have the extraordinary sex lives that only exist in the minds of those who should be able to see prejudice for what it is and women in developing countries are not highly promiscuous, callous, uncaring and careless about their lives and the lives of others, we have to look elsewhere for an answer to the oft repeated question: why is HIV transmission so different in a handful of African countries?
It is not for lack of evidence that the entire HIV industry still assumes that HIV is predominantly driven by heterosexual sex in African countries (though, unintuitively, not in non-African countries); the assumption is underpinned by these prejudices. There is nothing else supporting the assumption. There is ample evidence showing that the assumption is contradicted by everything we know, or should know.
Clearly it needs repeating: HIV is also transmitted non-sexuall, through unsafe healthcare, unsafe cosmetic practices and perhaps through other routes. Until these modes of transmission have been adequately quantified, it will not be known whether they play a greater or lesser part in HIV transmission than heterosexual sex. But we will have little impact on HIV transmission until we are clear where the majority of infections are coming from.
UNAIDS and the HIV industry don't like people to mention non-sexually transmitted HIV. That's fine, we can stop talking about once it has been investigated properly. But unless there is some mystery mode of transmission that has remained undiscovered up to now, we can't continue to pretend that it is all heterosexually transmitted in Africa when we know that's not true. There may be billions of dollars invested in sexually transmitted HIV, along with the reputations of a lot of institutions and people. Perhaps the ones who embrace the truth will gain first mover advantage.
I say 'might' because the HIV industry concludes from the fact that HIV is not easily transmitted through heterosexual sex, that Africans must have extraordinary amounts of sex. Evidence suggests that Africans don't have extraordinary amounts of sex, so the industry further concludes that almost all the sex Africans have is 'unsafe'.
Research has also makes it clear that only some people have a lot of sex, although quite a few Africans (and non-Africans) are reluctant to take precautions and engage in what is considered to be safe sex much of the time. But the majority of Africans, like the majority of non-Africans, just have ordinary amounts of sex, safe or otherwise.
More worryingly, 'safe' sex practices, such as later sexual debut, fewer partners, greater condom use, etc, are often correlated with similar and even higher rates of HIV transmission. Yet still, the HIV industry doesn't conclude that they should put aside their obsession with the sex lives of others and re-examine non-sexual modes of transmission.
Over the years, the industry has come up with one 'explanation' after another as to why very high heterosexual HIV transmission rates are only found in some countries and some parts of some countries, and they are all in Africa. Multiple partnerships was eventually shown not to explain high transmission rates so the concept of concurrency was added in.
But like sex and unsafe sex, evidence showed that only some people engage in concurrent partnerships, sexual partnerships that overlap. Most people don't engage in such partnerships. Also, concurrent partnerships are not exclusive to Africans. They occur everywhere, but without the massive rates of HIV transmission found in some African countries.
It didn't take HIV researchers long to compound the racism of their account of African sexuality with the racist assumption that Africans generally lie about their sexual behavior. Well, some do, as do some non-Africans. But anything that fails to fit the HIV industry picture of African sexuality is discounted as lies.
And the institutional racism itself is compounded by a form of institutional sexism. Women, under the orthodox model, appear to lie a lot more than men. We are told that, not only are they far more promiscuous than men, but they admit to far less promiscuity. The industry 'knows' that they are lying because HIV rates are far higher among women than an assumed greater susceptability could account for.
Few may be surprised to hear that academics, political and religious leaders, professionals of all kinds, journalists and many others are deeply racist and sexist. But I think it would come as a surprise to many to hear that the heterosexual HIV pandemic in African countries is driven by these prejudices.
If Africans don't have the extraordinary sex lives that only exist in the minds of those who should be able to see prejudice for what it is and women in developing countries are not highly promiscuous, callous, uncaring and careless about their lives and the lives of others, we have to look elsewhere for an answer to the oft repeated question: why is HIV transmission so different in a handful of African countries?
It is not for lack of evidence that the entire HIV industry still assumes that HIV is predominantly driven by heterosexual sex in African countries (though, unintuitively, not in non-African countries); the assumption is underpinned by these prejudices. There is nothing else supporting the assumption. There is ample evidence showing that the assumption is contradicted by everything we know, or should know.
Clearly it needs repeating: HIV is also transmitted non-sexuall, through unsafe healthcare, unsafe cosmetic practices and perhaps through other routes. Until these modes of transmission have been adequately quantified, it will not be known whether they play a greater or lesser part in HIV transmission than heterosexual sex. But we will have little impact on HIV transmission until we are clear where the majority of infections are coming from.
UNAIDS and the HIV industry don't like people to mention non-sexually transmitted HIV. That's fine, we can stop talking about once it has been investigated properly. But unless there is some mystery mode of transmission that has remained undiscovered up to now, we can't continue to pretend that it is all heterosexually transmitted in Africa when we know that's not true. There may be billions of dollars invested in sexually transmitted HIV, along with the reputations of a lot of institutions and people. Perhaps the ones who embrace the truth will gain first mover advantage.
Saturday, February 26, 2011
Why Are UNAIDS So Averse To Reducing HIV Transmission?
The usual headlines and the usual claims about the number of HIV infections prevented by male circumcision, this time in Swaziland. This time it's 88,000 new infections and, as always, there will never be any way of telling how many infections were prevented. Because the majority of men in Swaziland (over 80%) are HIV negative, it will be easy enough to cite a notional figure for how many men would have been infected if the surgeons hadn't jumped in and circumcised most of the men.
The circumcision enthusiasts could look at it another way and ask how many men were infected through heterosexual sex, because that's what circumcision is supposed to reduce. But if they scrutinized the figures too closely people might start to ask if circumcising hundreds of thousands of men (there are only just over one million Swazis), this could be an embarressment to the HIV orthodoxy, with their years of manufactured 'evidence'.
Male circumcision is said to reduce HIV transmission from females to males by up to 60%, but that's the highest figure, in trial conditions. It doesn't reduce transmission from females to males and it may well increase it. But we don't talk about that. And it is said to reduce transmission during penile-vaginal sex, not anal sex. It has no positive impact on transmission through anal sex, unsafe health care or unsafe cosmetic practices, whatsoever.
Now, the assumption is that those Swazis, being Africans, have a hell of a lot of sex, especially 'unsafe' sex, regardless of what they might say about their own sex lives. So UNAIDS and their collaborators calculate HIV transmission with the assumption that it's almost all heterosexually transmitted and that unsafe health care is almost non-existant. Unsafe cosmetic practices (tattooing, manicures, etc) are rarely mentioned.
The trouble with these assumptions is that they are all flatly contradicted by the very figures that the HIV industry usually use. The five yearly Demographic and Health Surveys, for Swaziland and other high HIV prevalence African countries, clearly show that most Africans are no more sexually active than non-Africans and, crucially, that levels of sexual activity, unsafe or otherwise, show little correspondence with HIV prevalence. Similar remarks apply to other high prevalence African countries.
Swaziland has some of the highest transmission rates in the world, but the most likely people to be infected are pregnant females. And why wouldn't they be vulnerable if they are clearly having unprotected sex? But it's not even the females who are having the most children that are most likely to be infected, it's usually the wealthiest and best educated who live in cities and suburbs. Poor, uneducated, rural-dwelling females are far less likely to be infected, regardless of their higher fertility rates.
And look at the male-female ratio for HIV prevalence: for every 5 females infected, there are only three males infected. We are told (incessantly) that women are more susceptible, which may well be true. But who is infecting them? Because UNAIDS and their allies claim that almost all females are infected sexually. Is there a merry band of males, who must be doing amazing amounts of work, going out of their way to spread HIV far and wide?
Even if most women, under the heterosexual transmission theory, are being infected by men, many men are not being infected by women. It's said to be roughly twice as difficult for a man to be infected by a woman than it is for a woman to be infected by a man (1 in 1000, compared to 1 in 500). But of the three men being infected for ever five women in Swaziland, some of those men are either infected through having sex with other men (MSM) or through intravenous drug use (IDU).
The HIV industry and the media love the idea that IDUs and even MSM also have sex with women. They love to talk about 'risk groups' and 'bridging groups' (people who are at high risk transmitting HIV to people who are at low risk). Some MSM and IDUs undoubtedly do have heterosexual sex, but many probably don't. Neither the media nor the industry can cite any reliable figures anyway. But there are clearly some men who are not infected through heterosexual sex and some who are not infected through any kind of sex.
If far more women than men are infected and many of the infected men are not infecting the women anyway, how appropriate is male circumcision when it comes to reducing HIV transmission? If you assume 80 or 90% heterosexual transmission then it's easy to produce glib figures, such as the 88,000 new infections mentioned. But unless you can show that most transmission is heterosexual, or even sexual, the circumcision intervention ceases to look so effective (if you were even persuaded in the first place!).
Carrying out unnecessary operations on millions of men is dangerous enough, but the promised reductions in HIV transmission will never materialize because they are based on a false premise about the high contribution that heterosexual transmission makes in high prevalence countries. Ignoring non-sexual transmission will not make it go away; the claimed millions of HIV infections that will be averted by mass male circumcision campaigns are false. But millions of new non-sexual infections will occur while the industry sits around patting each other on the back.
The circumcision enthusiasts could look at it another way and ask how many men were infected through heterosexual sex, because that's what circumcision is supposed to reduce. But if they scrutinized the figures too closely people might start to ask if circumcising hundreds of thousands of men (there are only just over one million Swazis), this could be an embarressment to the HIV orthodoxy, with their years of manufactured 'evidence'.
Male circumcision is said to reduce HIV transmission from females to males by up to 60%, but that's the highest figure, in trial conditions. It doesn't reduce transmission from females to males and it may well increase it. But we don't talk about that. And it is said to reduce transmission during penile-vaginal sex, not anal sex. It has no positive impact on transmission through anal sex, unsafe health care or unsafe cosmetic practices, whatsoever.
Now, the assumption is that those Swazis, being Africans, have a hell of a lot of sex, especially 'unsafe' sex, regardless of what they might say about their own sex lives. So UNAIDS and their collaborators calculate HIV transmission with the assumption that it's almost all heterosexually transmitted and that unsafe health care is almost non-existant. Unsafe cosmetic practices (tattooing, manicures, etc) are rarely mentioned.
The trouble with these assumptions is that they are all flatly contradicted by the very figures that the HIV industry usually use. The five yearly Demographic and Health Surveys, for Swaziland and other high HIV prevalence African countries, clearly show that most Africans are no more sexually active than non-Africans and, crucially, that levels of sexual activity, unsafe or otherwise, show little correspondence with HIV prevalence. Similar remarks apply to other high prevalence African countries.
Swaziland has some of the highest transmission rates in the world, but the most likely people to be infected are pregnant females. And why wouldn't they be vulnerable if they are clearly having unprotected sex? But it's not even the females who are having the most children that are most likely to be infected, it's usually the wealthiest and best educated who live in cities and suburbs. Poor, uneducated, rural-dwelling females are far less likely to be infected, regardless of their higher fertility rates.
And look at the male-female ratio for HIV prevalence: for every 5 females infected, there are only three males infected. We are told (incessantly) that women are more susceptible, which may well be true. But who is infecting them? Because UNAIDS and their allies claim that almost all females are infected sexually. Is there a merry band of males, who must be doing amazing amounts of work, going out of their way to spread HIV far and wide?
Even if most women, under the heterosexual transmission theory, are being infected by men, many men are not being infected by women. It's said to be roughly twice as difficult for a man to be infected by a woman than it is for a woman to be infected by a man (1 in 1000, compared to 1 in 500). But of the three men being infected for ever five women in Swaziland, some of those men are either infected through having sex with other men (MSM) or through intravenous drug use (IDU).
The HIV industry and the media love the idea that IDUs and even MSM also have sex with women. They love to talk about 'risk groups' and 'bridging groups' (people who are at high risk transmitting HIV to people who are at low risk). Some MSM and IDUs undoubtedly do have heterosexual sex, but many probably don't. Neither the media nor the industry can cite any reliable figures anyway. But there are clearly some men who are not infected through heterosexual sex and some who are not infected through any kind of sex.
If far more women than men are infected and many of the infected men are not infecting the women anyway, how appropriate is male circumcision when it comes to reducing HIV transmission? If you assume 80 or 90% heterosexual transmission then it's easy to produce glib figures, such as the 88,000 new infections mentioned. But unless you can show that most transmission is heterosexual, or even sexual, the circumcision intervention ceases to look so effective (if you were even persuaded in the first place!).
Carrying out unnecessary operations on millions of men is dangerous enough, but the promised reductions in HIV transmission will never materialize because they are based on a false premise about the high contribution that heterosexual transmission makes in high prevalence countries. Ignoring non-sexual transmission will not make it go away; the claimed millions of HIV infections that will be averted by mass male circumcision campaigns are false. But millions of new non-sexual infections will occur while the industry sits around patting each other on the back.
Saturday, February 19, 2011
Are Most HIV Positive Infants Infected by Their Mother or by Unsafe Healthcare
HIV figures from a recent survey in Mozambique paint a fairly typical picture of prevalence patterns in underdeveloped, high prevalence African countries. People in the richest quintile are three times more likely to be infected than those in the poorest quintile.
Women with secondary or higher education are 50% more likely to be infected than women with only primary education or less. Men are a lot less likely to be infected than women. And less well educated, poorer men are less likely to be infected than well educated, wealthier men.
So, what kind of transmission scenario is responsible for these patterns? Well, it is clear that more than one scenario is needed. The one official scenario used to explain all high prevalence African epidemics at the moment is that of unsafe sex.
We are supposed to believe that huge numbers of Africans engage in unsafe sex most of the time, despite safe sex messages and education being pumped out by the hour for many years. Apparently, those urban dwellers with greater access to the media and to the benefits of education, public services and health care are at greater risk of being infected.
Which tends to suggest that the single scenario is just wrong. But the 'behavioral paradigm', the belief that almost all HIV transmission occurs via heterosexual sex, is still the official view of UNAIDS, the US Center for Disease Control and most major academic institutions working with HIV.
To take one example, are we supposed to believe that rich women with higher levels of education living in urban areas have a tendency to pay people who are at high risk of being HIV positive to have sex with them? This may happen, but is it such a common phenomenon that it drives one of the worst HIV epidemics in the world?
Who exactly is infecting these women? Are they paying rich men to have sex with them? And if their rich, male spouses are paying for extramarital sex with high risk, casual partners, who are these partners? If they are poor, uneducated, rural dwelling people, they are less likely to be infected, in which case they are also less likely to be spreading the virus.
In order to explain why those with greater wealth, education and access to public services and healthcare are more likely to be infected, one needs to posit some other mode of transmission than heterosexual sex. Men who have sex with men (MSM) are a recognised risk group, as are injecting drug users (IDU). But these groups tend to infect other MSM and IDUs a lot more than people who belong to neither of these groups.
More than a hint at what could be going on comes from the same report that the above findings are based on, the Demographic and Health Survey. An estimated 30% of HIV positive infants have HIV negative mothers (the document is in Portuguese). If their mothers did not infect them it is highly likely that they were infected nosocomially, that is, through some kind of unsafe medical procedure, such as an injection. Anyone, infant, child or adult, can be infected nosocomially.
And not only can infants be infected by their mothers during delivery or breastfeeding, but infants can also infect their mothers through breastfeeding. This can happen if a baby is infected nosocomially. Also, the number of infants infected nosocomially may be a lot higher than 30%. The fact that the mother is HIV positive does not necessarily mean that the infant was infected by their mother.
The number of pregnant women and women who have recently given birth who seroconvert late in their pregnancy, or some time in the months following delivery, is very suspicious. Most women take precautions while they are pregnant and when they have recently given birth to protect themselves and their infants.
Are we supposed to believe that many African women are not just highly promiscuous but also either stupid or careless about their health and the health of their infants?
A far more convincing scenario to explain all of the above phenomena is that people are not only infected with HIV through heterosexual sex. Many, perhaps even a majority, are infected through unsafe healthcare.
Women, especially those around childbearing age, face more invasive medical treatment than men. Richer people can afford more healthcare than poorer people, who often do without altogether. And those in urban areas have greater access to healthcare while those in rural areas often have no access whatsoever.
Some HIV transmission may occur through heterosexual sex, especially in a country where prevalence has reached such alarming levels. And those who are infected nosocomially can also transmit HIV sexually. But at present they are not considered to be 'high risk', nosocomial infection is not targeted by HIV prevention campaigns and people at risk don't even know about the risks they face from unsafe healthcare.
The single scenario, naive theory of HIV transmission through heterosexual sex raises more questions than it answers. But the dual scenario, non-sexual and sexual transmission theory answers all of the questions. None of these remarks are particularly new, nor do they apply to Mozambigue alone. So now all we have to do is convince UNAIDS, CDC and other big players in the HIV industry.
Women with secondary or higher education are 50% more likely to be infected than women with only primary education or less. Men are a lot less likely to be infected than women. And less well educated, poorer men are less likely to be infected than well educated, wealthier men.
So, what kind of transmission scenario is responsible for these patterns? Well, it is clear that more than one scenario is needed. The one official scenario used to explain all high prevalence African epidemics at the moment is that of unsafe sex.
We are supposed to believe that huge numbers of Africans engage in unsafe sex most of the time, despite safe sex messages and education being pumped out by the hour for many years. Apparently, those urban dwellers with greater access to the media and to the benefits of education, public services and health care are at greater risk of being infected.
Which tends to suggest that the single scenario is just wrong. But the 'behavioral paradigm', the belief that almost all HIV transmission occurs via heterosexual sex, is still the official view of UNAIDS, the US Center for Disease Control and most major academic institutions working with HIV.
To take one example, are we supposed to believe that rich women with higher levels of education living in urban areas have a tendency to pay people who are at high risk of being HIV positive to have sex with them? This may happen, but is it such a common phenomenon that it drives one of the worst HIV epidemics in the world?
Who exactly is infecting these women? Are they paying rich men to have sex with them? And if their rich, male spouses are paying for extramarital sex with high risk, casual partners, who are these partners? If they are poor, uneducated, rural dwelling people, they are less likely to be infected, in which case they are also less likely to be spreading the virus.
In order to explain why those with greater wealth, education and access to public services and healthcare are more likely to be infected, one needs to posit some other mode of transmission than heterosexual sex. Men who have sex with men (MSM) are a recognised risk group, as are injecting drug users (IDU). But these groups tend to infect other MSM and IDUs a lot more than people who belong to neither of these groups.
More than a hint at what could be going on comes from the same report that the above findings are based on, the Demographic and Health Survey. An estimated 30% of HIV positive infants have HIV negative mothers (the document is in Portuguese). If their mothers did not infect them it is highly likely that they were infected nosocomially, that is, through some kind of unsafe medical procedure, such as an injection. Anyone, infant, child or adult, can be infected nosocomially.
And not only can infants be infected by their mothers during delivery or breastfeeding, but infants can also infect their mothers through breastfeeding. This can happen if a baby is infected nosocomially. Also, the number of infants infected nosocomially may be a lot higher than 30%. The fact that the mother is HIV positive does not necessarily mean that the infant was infected by their mother.
The number of pregnant women and women who have recently given birth who seroconvert late in their pregnancy, or some time in the months following delivery, is very suspicious. Most women take precautions while they are pregnant and when they have recently given birth to protect themselves and their infants.
Are we supposed to believe that many African women are not just highly promiscuous but also either stupid or careless about their health and the health of their infants?
A far more convincing scenario to explain all of the above phenomena is that people are not only infected with HIV through heterosexual sex. Many, perhaps even a majority, are infected through unsafe healthcare.
Women, especially those around childbearing age, face more invasive medical treatment than men. Richer people can afford more healthcare than poorer people, who often do without altogether. And those in urban areas have greater access to healthcare while those in rural areas often have no access whatsoever.
Some HIV transmission may occur through heterosexual sex, especially in a country where prevalence has reached such alarming levels. And those who are infected nosocomially can also transmit HIV sexually. But at present they are not considered to be 'high risk', nosocomial infection is not targeted by HIV prevention campaigns and people at risk don't even know about the risks they face from unsafe healthcare.
The single scenario, naive theory of HIV transmission through heterosexual sex raises more questions than it answers. But the dual scenario, non-sexual and sexual transmission theory answers all of the questions. None of these remarks are particularly new, nor do they apply to Mozambigue alone. So now all we have to do is convince UNAIDS, CDC and other big players in the HIV industry.
Wednesday, February 16, 2011
Researchers Seek Answers But Reject the Bits they Don't Like
The fact that very high HIV prevalence is found in some countries and not in others is usually explained in terms of differences in rates of sexual behavior, especially 'unsafe' sexual behavior. However, it has never been demonstrated that rates of sexual behavior, unsafe or otherwise, really are higher in areas where HIV prevalence is high.
A recent article on herpes simplex virus (HSV-2) is a case in point (HSV-2 Among Bar and Hotel Workers in Northern Tanzania, Kapiga, Sam, Shao et al). A group of bar and hotel workers in Moshi, Tanzania, were studied and HSV-2 prevalence was found to be 43.5%. In the US, 22% of people aged 12 years or over are infected with HSV-2. Rates of unsafe sex probably explain high HSV-2 prevalence found in both countries, but that doesn't explain low HIV rates in US, nor high rates in Tanzania.
These two HSV-2 figures may look very different until you consider that unsafe sexual behavior is thought to be more common among bar and hotel workers in African countries than it is among the general population. HSV-2 prevalence increases with age, also, so prevalence among a comparable group in the US could be expected to be a lot closer to prevalence found in the Tanzanian group.
HSV-2 is almost always transmitted sexually. HIV is sometimes transmitted sexually, though heterosexual sex is an inefficient route of transmission. HIV is far more efficiently transmitted through various non-sexual routes, such as unsafe health care, especially through contaminated injecting equipment.
The relative contribution of sexual and non-sexual transmission of HIV to high prevalence HIV epidemics, such as those found in some African countries, is not known. The assumption that HIV is almost always transmitted sexually in African countries is, therefore, without foundation. And the figures for HSV-2 prevalence in the US and Tanzania suggest that rates of unsafe sexual behavior are similar, so difference in HIV prevalence is probably due to non-sexual factors.
The problem is that high levels of unsafe sexual behavior in (some) African countries are inferred from the fact that HIV prevalence is high and low levels of unsafe sexual behavior in Western countries are inferred from the fact that HIV prevalence is low. Yet, rates for some types of unsafe sexual behavior, age at sexual debut, number of sexual partners, overlapping sexual partners, etc, are probably very similar in both African and non-African countries. Not a lot of research has focused on comparing the two.
The paper studying HSV-2 shows that condom use is low and inconsistent, so it's not surprising that rates of sexually transmitted infections are high. But, while consistent condom use may protect against sexual HIV transmission, it does not protect against non-sexual HIV transmission. Therefore HSV-2 patterns in Moshi were, in many respects, quite different from HIV patterns.
For example, women were 4 times more likely to be infected with HSV-2 than men, prevalence standing at 53.1% and 29.2%, respectively. But women were almost 10 times more likely to be HIV positive than men. HSV-2 increases the probability of transmitting HIV and of being infected with HIV, but because one is almost always sexually transmitted and the other is only sometimes sexually transmitted, infection patterns remain distinct.
In Tanzania, HIV prevalence is higher among Christians than among Muslims. The opposite is true of HSV-2, which has a 50% lower risk among Catholics (the finding was not significant among non-Catholics). Rates of unsafe sexual behavior are also found to be higher among Muslims (multiple partnerships and concurrent relationships), which could explain higher rates of HSV-2 but only explains lower rates of HIV if you accept that HIV must also be transmitted non-sexually.
The complex relationships between levels of education and HSV-2 and HIV prevalence, respectively, are also quite different. The authors of this paper interpret both diseases purely in terms of sexual transmission, which muddies the waters. But while HSV-2 rates go down with increasing education among women, HIV rates go up.
The authors speculate about possible correlations between relative levels of income/wealth and HSV-2 transmission but don't produce any relevant figures. This is a pity because unsafe sexual behavior may well be higher among females with lower incomes but HIV rates in Tanzania are often higher among wealthier women.
The age patterns for HSV-2 and HIV prevalence are also quite different, with HSV-2 rates rising with increasing age. HIV rates in women are much more closely connected with pregnancy and childbearing, which carry increased levels of non-sexual risk. HIV rates among men start to rise later in life and peak somewhat later than among women.
Also HSV-2 is rare in non-sexually active people, especially the very young. But rates of HIV can sometimes be alarmingly high among these groups. Prevalence among male and female children are quite similar, suggesting similar levels of risk. HIV rates in adult females are almost always higher than in males in high prevalence countries (and almost always far lower than in males in low prevalence countries).
The researchers were surprised to find that women who had uncircumcised sex partners had a 50% reduction in HSV-2 risk. The Tanzanian government is currently considering circumcising 2.8 million men because they have been convinced that it will reduce HIV transmission from women to men. So it might be worth doing some unbiased research before carrying out such a risky intervention.
So the article may tell us a lot about HSV-2 and sexual risk, and might even shed some light on sexually transmitted HIV. But it assumes that HIV is, like HSV-2, a sexually transmitted infection, which is certainly not accurate and may even be dangerously inaccurate.
The article gives little insight into why HIV prevalence is so high in some parts of some African countries. Yet the authors purport to find implications for HIV prevention. But such implications are unlikely to be significant or helpful unless the relative contributions of sexually and non-sexually transmitted HIV are also quantified.
A recent article on herpes simplex virus (HSV-2) is a case in point (HSV-2 Among Bar and Hotel Workers in Northern Tanzania, Kapiga, Sam, Shao et al). A group of bar and hotel workers in Moshi, Tanzania, were studied and HSV-2 prevalence was found to be 43.5%. In the US, 22% of people aged 12 years or over are infected with HSV-2. Rates of unsafe sex probably explain high HSV-2 prevalence found in both countries, but that doesn't explain low HIV rates in US, nor high rates in Tanzania.
These two HSV-2 figures may look very different until you consider that unsafe sexual behavior is thought to be more common among bar and hotel workers in African countries than it is among the general population. HSV-2 prevalence increases with age, also, so prevalence among a comparable group in the US could be expected to be a lot closer to prevalence found in the Tanzanian group.
HSV-2 is almost always transmitted sexually. HIV is sometimes transmitted sexually, though heterosexual sex is an inefficient route of transmission. HIV is far more efficiently transmitted through various non-sexual routes, such as unsafe health care, especially through contaminated injecting equipment.
The relative contribution of sexual and non-sexual transmission of HIV to high prevalence HIV epidemics, such as those found in some African countries, is not known. The assumption that HIV is almost always transmitted sexually in African countries is, therefore, without foundation. And the figures for HSV-2 prevalence in the US and Tanzania suggest that rates of unsafe sexual behavior are similar, so difference in HIV prevalence is probably due to non-sexual factors.
The problem is that high levels of unsafe sexual behavior in (some) African countries are inferred from the fact that HIV prevalence is high and low levels of unsafe sexual behavior in Western countries are inferred from the fact that HIV prevalence is low. Yet, rates for some types of unsafe sexual behavior, age at sexual debut, number of sexual partners, overlapping sexual partners, etc, are probably very similar in both African and non-African countries. Not a lot of research has focused on comparing the two.
The paper studying HSV-2 shows that condom use is low and inconsistent, so it's not surprising that rates of sexually transmitted infections are high. But, while consistent condom use may protect against sexual HIV transmission, it does not protect against non-sexual HIV transmission. Therefore HSV-2 patterns in Moshi were, in many respects, quite different from HIV patterns.
For example, women were 4 times more likely to be infected with HSV-2 than men, prevalence standing at 53.1% and 29.2%, respectively. But women were almost 10 times more likely to be HIV positive than men. HSV-2 increases the probability of transmitting HIV and of being infected with HIV, but because one is almost always sexually transmitted and the other is only sometimes sexually transmitted, infection patterns remain distinct.
In Tanzania, HIV prevalence is higher among Christians than among Muslims. The opposite is true of HSV-2, which has a 50% lower risk among Catholics (the finding was not significant among non-Catholics). Rates of unsafe sexual behavior are also found to be higher among Muslims (multiple partnerships and concurrent relationships), which could explain higher rates of HSV-2 but only explains lower rates of HIV if you accept that HIV must also be transmitted non-sexually.
The complex relationships between levels of education and HSV-2 and HIV prevalence, respectively, are also quite different. The authors of this paper interpret both diseases purely in terms of sexual transmission, which muddies the waters. But while HSV-2 rates go down with increasing education among women, HIV rates go up.
The authors speculate about possible correlations between relative levels of income/wealth and HSV-2 transmission but don't produce any relevant figures. This is a pity because unsafe sexual behavior may well be higher among females with lower incomes but HIV rates in Tanzania are often higher among wealthier women.
The age patterns for HSV-2 and HIV prevalence are also quite different, with HSV-2 rates rising with increasing age. HIV rates in women are much more closely connected with pregnancy and childbearing, which carry increased levels of non-sexual risk. HIV rates among men start to rise later in life and peak somewhat later than among women.
Also HSV-2 is rare in non-sexually active people, especially the very young. But rates of HIV can sometimes be alarmingly high among these groups. Prevalence among male and female children are quite similar, suggesting similar levels of risk. HIV rates in adult females are almost always higher than in males in high prevalence countries (and almost always far lower than in males in low prevalence countries).
The researchers were surprised to find that women who had uncircumcised sex partners had a 50% reduction in HSV-2 risk. The Tanzanian government is currently considering circumcising 2.8 million men because they have been convinced that it will reduce HIV transmission from women to men. So it might be worth doing some unbiased research before carrying out such a risky intervention.
So the article may tell us a lot about HSV-2 and sexual risk, and might even shed some light on sexually transmitted HIV. But it assumes that HIV is, like HSV-2, a sexually transmitted infection, which is certainly not accurate and may even be dangerously inaccurate.
The article gives little insight into why HIV prevalence is so high in some parts of some African countries. Yet the authors purport to find implications for HIV prevention. But such implications are unlikely to be significant or helpful unless the relative contributions of sexually and non-sexually transmitted HIV are also quantified.
Saturday, February 12, 2011
Unsafe Health Care: the Most Efficient Means of Spreading HIV
I have often suggested on this blog that non-sexual HIV transmission could be as common as, or perhaps more common than, sexual HIV transmission. Not only do I not know the exact extent of either modes of transmission, but nor does anyone else. And I don't know of very many people who are trying to find out. Certainly none of the HIV orthodoxy.
The issue of HIV transmission in health facilities is particularly maligned by the HIV industry, who say little about it except to deny that it occurs to any great extent, even in developing countries with atrocious health facility conditions. This denial is based on anecdote, supposition and profound anti-African prejudice.
But nosocomial transmission of various diseases occurs in every country. The only difference between rich countries and poor countries is that when it occurs in a rich country, there is usually (not always, as I will argue in a future post) a thorough investigation. People who may have been exposed to diseases are recalled for testing, etc. There is no such investigation or recalling in developing countries.
Here's an example: a surgeon uses an unsterilized pair of scissors in operations, not just few times but on over 100 children. He denied operating without gloves, as well, so it may not have been just the children's health that was put at risk.
This didn't happen in a developing country, it happened in a prestigious teaching hospital in Cambridge, UK. The surgeon was sacked and the children were recalled for tests. Whether any of them were infected or received any treatment as a result of the incident (or series of incidents), is not clear. But it's good to know that someone is checking and that something happens when things go wrong.
Here's another example: a nurse thought that a machine used to check blood sugar levels automatically changed needles. It didn't, but it took two months and 55 exposed people before anyone noticed. This happened in a private radiology clinic in Australia.
A spokesperson for the facility may be right in claiming that the risk of infection is very low. In a country like Australia, there are probably not that many people visiting health facilities with undiagnosed HIV, though I'm not so sure about hepatitis B, C or other blood borne diseases. And in the UK, it's unlikely many children have HIV infections, diagnosed or undiagnosed.
But in countries where prevalence of HIV is high and prevalence of hepatitis and other diseases even higher, the risk could be tens or even hundreds of times higher. Even among children and infants in developing countries, rates can be high enough to seriously threaten the safety of those undergoing medical treatment. Undiagnosed infections could be especially common.
And just look at the numbers involved here: over 170 people at risk because of the actions of two people. Compare this with sexual HIV transmission, where most people are unlikely to infect more than one other person except under relatively ususual conditions. A handful of highly sexually active people may be able to infect a handful more and spark off a small epidemic. But only professionals can spark off the massive rates of transmission found in some sub-Saharan African countries.
A third example, and these are just ones I picked up this week: 535 attendees at a Veterans' Affairs medical facility have been recalled for testing because one dentist failed to change his gloves between patients. These failures went on for 18 years. Nor did he always sterilize all his equipment. In this instance, the person involved is still employed.
UNAIDS and the HIV industry start with the assumption (it's not a hypothesis because they refuse to modify it despite evidence that it is unwarranted) that 90% (or some such figure) of HIV in African countries is transmitted through heterosexual sex by 'promiscuous' people.
They then have to show that some people really have the amount of sex required to spread a difficult to transmit virus to the extent that it affects a large proportion of the sexually active population. And that's no small amount of sex. In fact, it's a humanly impossible amount of sex, even for commercial sex workers (and anyone else the industry finger has been pointed at, truckers, migrant workers, soldiers, teachers, etc).
For the 'reproductive number', the number of people who are subsequently infected by each infected person, to be high enough to explain the number of people infected in some countries by sexual transmission alone, people would need to be more than just promiscuous.
On the other hand, nosocomial HIV transmission is very efficient. One person can put hundreds at risk, even hundreds per year. The risk of infection for each patient who received unsafe treatment is far higher than the risk they would have faced if they had numerous unprotected penetrative sexual experiences with a HIV positive person.
Epidemiologists often talk about 'explosive' epidemics, especially in relation to HIV. But HIV as a heterosexually transmitted infection is not, by any stretch, an explosive virus. It is explosive among men who have sex with men, among injection drug users and, presumably, among women who engage in heterosexual anal sex. It is also explosive in unsafe health care contexts, highly explosive. The above figures are the tip of the iceberg because they come from rich country health facilities where something went wrong.
In poor countries, many people don't receive much health care. Those who do take their chances and many things go wrong. In African countries where health care was once available to many, HIV prevalence appears to be very high, or was once high. Zimbabwe and South Africa are two examples. In East African countries, where health care is inaccessible to most, prevalence rates are far lower, though high enough to suggest large levels of nosocomial infection.
I'm beyond calling for HIV academics to change their prejudiced attitudes, they don't see themselves as prejudiced. They don't see how ill-founded their arguments are, nor how they all stem from the 'behavioral paradigm', the belief that almost all HIV is heterosexually transmitted in African countries. They could retain these extreme racist and sexist views and still investigate levels of nosocomial HIV transmission.
The issue of HIV transmission in health facilities is particularly maligned by the HIV industry, who say little about it except to deny that it occurs to any great extent, even in developing countries with atrocious health facility conditions. This denial is based on anecdote, supposition and profound anti-African prejudice.
But nosocomial transmission of various diseases occurs in every country. The only difference between rich countries and poor countries is that when it occurs in a rich country, there is usually (not always, as I will argue in a future post) a thorough investigation. People who may have been exposed to diseases are recalled for testing, etc. There is no such investigation or recalling in developing countries.
Here's an example: a surgeon uses an unsterilized pair of scissors in operations, not just few times but on over 100 children. He denied operating without gloves, as well, so it may not have been just the children's health that was put at risk.
This didn't happen in a developing country, it happened in a prestigious teaching hospital in Cambridge, UK. The surgeon was sacked and the children were recalled for tests. Whether any of them were infected or received any treatment as a result of the incident (or series of incidents), is not clear. But it's good to know that someone is checking and that something happens when things go wrong.
Here's another example: a nurse thought that a machine used to check blood sugar levels automatically changed needles. It didn't, but it took two months and 55 exposed people before anyone noticed. This happened in a private radiology clinic in Australia.
A spokesperson for the facility may be right in claiming that the risk of infection is very low. In a country like Australia, there are probably not that many people visiting health facilities with undiagnosed HIV, though I'm not so sure about hepatitis B, C or other blood borne diseases. And in the UK, it's unlikely many children have HIV infections, diagnosed or undiagnosed.
But in countries where prevalence of HIV is high and prevalence of hepatitis and other diseases even higher, the risk could be tens or even hundreds of times higher. Even among children and infants in developing countries, rates can be high enough to seriously threaten the safety of those undergoing medical treatment. Undiagnosed infections could be especially common.
And just look at the numbers involved here: over 170 people at risk because of the actions of two people. Compare this with sexual HIV transmission, where most people are unlikely to infect more than one other person except under relatively ususual conditions. A handful of highly sexually active people may be able to infect a handful more and spark off a small epidemic. But only professionals can spark off the massive rates of transmission found in some sub-Saharan African countries.
A third example, and these are just ones I picked up this week: 535 attendees at a Veterans' Affairs medical facility have been recalled for testing because one dentist failed to change his gloves between patients. These failures went on for 18 years. Nor did he always sterilize all his equipment. In this instance, the person involved is still employed.
UNAIDS and the HIV industry start with the assumption (it's not a hypothesis because they refuse to modify it despite evidence that it is unwarranted) that 90% (or some such figure) of HIV in African countries is transmitted through heterosexual sex by 'promiscuous' people.
They then have to show that some people really have the amount of sex required to spread a difficult to transmit virus to the extent that it affects a large proportion of the sexually active population. And that's no small amount of sex. In fact, it's a humanly impossible amount of sex, even for commercial sex workers (and anyone else the industry finger has been pointed at, truckers, migrant workers, soldiers, teachers, etc).
For the 'reproductive number', the number of people who are subsequently infected by each infected person, to be high enough to explain the number of people infected in some countries by sexual transmission alone, people would need to be more than just promiscuous.
On the other hand, nosocomial HIV transmission is very efficient. One person can put hundreds at risk, even hundreds per year. The risk of infection for each patient who received unsafe treatment is far higher than the risk they would have faced if they had numerous unprotected penetrative sexual experiences with a HIV positive person.
Epidemiologists often talk about 'explosive' epidemics, especially in relation to HIV. But HIV as a heterosexually transmitted infection is not, by any stretch, an explosive virus. It is explosive among men who have sex with men, among injection drug users and, presumably, among women who engage in heterosexual anal sex. It is also explosive in unsafe health care contexts, highly explosive. The above figures are the tip of the iceberg because they come from rich country health facilities where something went wrong.
In poor countries, many people don't receive much health care. Those who do take their chances and many things go wrong. In African countries where health care was once available to many, HIV prevalence appears to be very high, or was once high. Zimbabwe and South Africa are two examples. In East African countries, where health care is inaccessible to most, prevalence rates are far lower, though high enough to suggest large levels of nosocomial infection.
I'm beyond calling for HIV academics to change their prejudiced attitudes, they don't see themselves as prejudiced. They don't see how ill-founded their arguments are, nor how they all stem from the 'behavioral paradigm', the belief that almost all HIV is heterosexually transmitted in African countries. They could retain these extreme racist and sexist views and still investigate levels of nosocomial HIV transmission.
Friday, February 11, 2011
UNAIDS Stigmatizes Sex Workers and Africans
John Potterat, Devon Brewer and others published a paper over 7 years ago showing that deaths from AIDS in a group of US sex workers were exclusively among those who admitted to injecting drugs or were inferred to have a history of doing so. Sex workers in the cohort faced many risks that could have lead to their death, but sexually transmitted HIV didn't seem to be one of them.
A study carried out in the late 90s in Italy, by Michele Spina, Salvatrice Mancuso and others, estimated HIV prevalence and condom use in a group of sex workers. HIV rates were higher than in the general population (though lower than in many high prevalence African countries). But the majority of the HIV positive women were injection drug users.
Condom use with paying customers was probably higher than would be found in African countries. But the fact that some of the HIV positive women were not injection drug users does not mean they were infected sexually, either. In reality, sex, even unprotected sex, has not been demonstrated to be the main risk factor in HIV transmission.
A third study, carried out 5 years ago in Uzbekistan by Catherine Todd, Mumtaz Khakimov and others looked at HIV prevalence among sex workers and the sort of risks they face. The majority of infections were among those who injected drugs. A fairly substantial number who didn't inject drugs were also infected. And treatment for a sexually transmitted infection (STI) was also found to be a risk factor. But non-sexual risks don't seem to have been taken into account.
I'm not suggesting that sex work is not hazardous, or that one of the risks sex workers face is not infection with (and transmission of) HIV. I just think that the risk of sexual transmission in sex workers in developing countries is exaggerated. I think the very fact that people are sex workers leads to the assumption that if they are HIV positive, they must have been infected sexually.
I think a similar assumption is made about HIV positive people who are not sex workers, that if they are HIV positive and they admit to being sexually active, they must have been infected sexually. This is the normal assumption in African countries. They may have been infected sexually, but couldn't a proper assessment be made of the non-sexual risks they have faced, as well as the sexual risks?
The assumption that Africans are almost always infected with HIV sexually leads to the ridiculous conclusion that even those who have never had sex, have only had sex with one, HIV negative partner or those who only ever engage in very low risk sex, if they test HIV positive, must also have been infected sexually.
The possibility that some people, perhaps a large number, have been infected non-sexually, is generally dismissed by the HIV orthodoxy. This is despite the appalling conditions in health services in African countries. It could be that people who have to attend health facilities actually face the highest risks of HIV infection.
Take sex workers, for example. They often attend clinics every few months for checkups, injectible contraceptives (the most popular form of contraceptive for sex workers and non-sex workers alike), for treatment for STIs and other invasive procedures. If any procedures in the facilities they visit are unsterile, the chances of nosocomial transmission of HIV (transmission through medical procedures) and other diseases are very high.
Take pregnant women as another example. They make visits to ante-natal clinics and undergo various invasive procedures, including injections. They may make several visits to clinics, before and after delivery. Every visit is a risk if medical practices are unsafe. And HIV rates are particularly high among pregnant women, who often seroconvert very late in their pregnancy or even after they give birth.
UNAIDS and other institutions connected with the AIDS industry usually ignore nosocomial HIV transmission, or they downplay it and claim its contribution to African epidemics is negligible. But how could it be negligible in some of the filthiest, most underfunded and understaffed facilities in the world when it is a significant risk in other countries, where conditions are far better?
While UNAIDS downplay the risks faced by Africans, they warn their own employees to avoid African health facilities because of the possible risks of nosocomial infection and unsafe healthcare in general. How could it be a risk to a rich UN employee and not to a poor African? The WHO accepts that a significant percentage of injections in African countries are contaminated. So it's time to consider non-sexual HIV risks when developing HIV prevention programs; it's time to rewrite global HIV prevention policy.
A study carried out in the late 90s in Italy, by Michele Spina, Salvatrice Mancuso and others, estimated HIV prevalence and condom use in a group of sex workers. HIV rates were higher than in the general population (though lower than in many high prevalence African countries). But the majority of the HIV positive women were injection drug users.
Condom use with paying customers was probably higher than would be found in African countries. But the fact that some of the HIV positive women were not injection drug users does not mean they were infected sexually, either. In reality, sex, even unprotected sex, has not been demonstrated to be the main risk factor in HIV transmission.
A third study, carried out 5 years ago in Uzbekistan by Catherine Todd, Mumtaz Khakimov and others looked at HIV prevalence among sex workers and the sort of risks they face. The majority of infections were among those who injected drugs. A fairly substantial number who didn't inject drugs were also infected. And treatment for a sexually transmitted infection (STI) was also found to be a risk factor. But non-sexual risks don't seem to have been taken into account.
I'm not suggesting that sex work is not hazardous, or that one of the risks sex workers face is not infection with (and transmission of) HIV. I just think that the risk of sexual transmission in sex workers in developing countries is exaggerated. I think the very fact that people are sex workers leads to the assumption that if they are HIV positive, they must have been infected sexually.
I think a similar assumption is made about HIV positive people who are not sex workers, that if they are HIV positive and they admit to being sexually active, they must have been infected sexually. This is the normal assumption in African countries. They may have been infected sexually, but couldn't a proper assessment be made of the non-sexual risks they have faced, as well as the sexual risks?
The assumption that Africans are almost always infected with HIV sexually leads to the ridiculous conclusion that even those who have never had sex, have only had sex with one, HIV negative partner or those who only ever engage in very low risk sex, if they test HIV positive, must also have been infected sexually.
The possibility that some people, perhaps a large number, have been infected non-sexually, is generally dismissed by the HIV orthodoxy. This is despite the appalling conditions in health services in African countries. It could be that people who have to attend health facilities actually face the highest risks of HIV infection.
Take sex workers, for example. They often attend clinics every few months for checkups, injectible contraceptives (the most popular form of contraceptive for sex workers and non-sex workers alike), for treatment for STIs and other invasive procedures. If any procedures in the facilities they visit are unsterile, the chances of nosocomial transmission of HIV (transmission through medical procedures) and other diseases are very high.
Take pregnant women as another example. They make visits to ante-natal clinics and undergo various invasive procedures, including injections. They may make several visits to clinics, before and after delivery. Every visit is a risk if medical practices are unsafe. And HIV rates are particularly high among pregnant women, who often seroconvert very late in their pregnancy or even after they give birth.
UNAIDS and other institutions connected with the AIDS industry usually ignore nosocomial HIV transmission, or they downplay it and claim its contribution to African epidemics is negligible. But how could it be negligible in some of the filthiest, most underfunded and understaffed facilities in the world when it is a significant risk in other countries, where conditions are far better?
While UNAIDS downplay the risks faced by Africans, they warn their own employees to avoid African health facilities because of the possible risks of nosocomial infection and unsafe healthcare in general. How could it be a risk to a rich UN employee and not to a poor African? The WHO accepts that a significant percentage of injections in African countries are contaminated. So it's time to consider non-sexual HIV risks when developing HIV prevention programs; it's time to rewrite global HIV prevention policy.
Tuesday, December 21, 2010
Anal Sex Can Be Dangerous But Likely to Be Ignored in African Countries
Ostensibly, Kenya's Modes of Transmission Survey aims to establish what factors are driving the country's HIV epidemic. I say 'ostensibly' because there are two glaring figures that cast doubt on all the other figures. The first is the figure for men having sex with men (MSM), which is lumped together with HIV in prison populations. The second is the figure for health facility related infections, which, at 2.5%, is extremely low compared to WHO figures for unsafe injections alone, which could be 8 or 9 times higher.
However, I've mentioned health facility related infections on many occasions, so I'll concentrate on MSM on this occasion. Prison populations would be at risk of HIV transmission through heterosexual sex, like everyone else. But more importantly, those infected through intravenous drug use are more likely to be in prison, given that the practice is a crime. Those in prisons may also be more likely to be infected through tattooing, taking blood oaths and, arguably, through unsafe healthcare.
That puts the provenance of one third of Kenya's HIV infections in serious doubt, the proportion either claimed to be or suspected of being from MSM and/or unsafe healthcare. The fact that another half of infections are said to come from relatively low risk sex makes the Survey seem like a pretty blunt instrument. But anal sex, whether homosexual or heterosexual, is known to be high risk sex. And, despite the need to target MSM, it is completely unclear what proportion of people engage in this practice.
What is clear is that MSM (and others engaging in anal sex) are not targeted particularly well. For a start, the practice is illegal and the country's Prime Minister Odinga recently called for the arrest and imprisonment of all practicing homosexuals. As a result of such attitudes and outbursts, who Kenya's MSM are and where they are is not only unclear, but likely to remain so.
Given these circumstances, it's not surprising that a survey of male sex workers providing services to men in Mombasa found that 35% of respondents did not know that HIV can be transmitted through anal sex. It is therefore unlikely that heterosexuals are aware that anal sex is an efficient transmitter of HIV, regardless of the gender of those involved, or that it is far more dangerous for the receptive partner.
Just over 20% knew that a water based lubricant should be used with latex condoms and again, it seems unlikely that heterosexuals engaging in anal sex are any more likely to know this. They are probably less likely to be targeted with correct information, despite evidence that many people think that anal sex does not transmit HIV at all. Even if people knew, they would be unlikely to find an appropriate lubricant easily. Many are said to resort to household products, some of which are more likely to weaken condoms than reduce the risk in any way.
Odinga, the Modes of Transmission Survey and the current calls for homosexuality to be punished even more severely than it already is suggests that Kenya is more interested in pointing the finger than in dealing with serious problems that are not just going to disappear. After frittering away tens of millions of dollars of donated HIV funds, Kenya was refused funding on several occasions.
And now, despite the continued lack of transparency, the Global Fund has decided to give the country nearly 40 billion Kenyan shillings in funding. The Global Fund, going by its title, is earmarked for HIV, TB and malaria, rather than for health systems or infrastructure. So its effects are going to be limited.
But ignoring risky sex (along with most non-sexual modes of transmission) and concentrating mainly on those who don't engage in risky sex seems like completely the wrong way to go about things. For a start, let's stop pretending that the majority of people are at risk of being infected sexually and find out why people engaging in low risk sex seem to be the largest contributor to Kenya's HIV epidemic.
The least we can ask of the Global Fund, then, is that even if they are not prepared to spend anything on non-sexually transmitted HIV, they should seriously consider targeting those who are genuinely at risk of sexual transmission: MSM and sex workers, and perhaps some others.
However, I've mentioned health facility related infections on many occasions, so I'll concentrate on MSM on this occasion. Prison populations would be at risk of HIV transmission through heterosexual sex, like everyone else. But more importantly, those infected through intravenous drug use are more likely to be in prison, given that the practice is a crime. Those in prisons may also be more likely to be infected through tattooing, taking blood oaths and, arguably, through unsafe healthcare.
That puts the provenance of one third of Kenya's HIV infections in serious doubt, the proportion either claimed to be or suspected of being from MSM and/or unsafe healthcare. The fact that another half of infections are said to come from relatively low risk sex makes the Survey seem like a pretty blunt instrument. But anal sex, whether homosexual or heterosexual, is known to be high risk sex. And, despite the need to target MSM, it is completely unclear what proportion of people engage in this practice.
What is clear is that MSM (and others engaging in anal sex) are not targeted particularly well. For a start, the practice is illegal and the country's Prime Minister Odinga recently called for the arrest and imprisonment of all practicing homosexuals. As a result of such attitudes and outbursts, who Kenya's MSM are and where they are is not only unclear, but likely to remain so.
Given these circumstances, it's not surprising that a survey of male sex workers providing services to men in Mombasa found that 35% of respondents did not know that HIV can be transmitted through anal sex. It is therefore unlikely that heterosexuals are aware that anal sex is an efficient transmitter of HIV, regardless of the gender of those involved, or that it is far more dangerous for the receptive partner.
Just over 20% knew that a water based lubricant should be used with latex condoms and again, it seems unlikely that heterosexuals engaging in anal sex are any more likely to know this. They are probably less likely to be targeted with correct information, despite evidence that many people think that anal sex does not transmit HIV at all. Even if people knew, they would be unlikely to find an appropriate lubricant easily. Many are said to resort to household products, some of which are more likely to weaken condoms than reduce the risk in any way.
Odinga, the Modes of Transmission Survey and the current calls for homosexuality to be punished even more severely than it already is suggests that Kenya is more interested in pointing the finger than in dealing with serious problems that are not just going to disappear. After frittering away tens of millions of dollars of donated HIV funds, Kenya was refused funding on several occasions.
And now, despite the continued lack of transparency, the Global Fund has decided to give the country nearly 40 billion Kenyan shillings in funding. The Global Fund, going by its title, is earmarked for HIV, TB and malaria, rather than for health systems or infrastructure. So its effects are going to be limited.
But ignoring risky sex (along with most non-sexual modes of transmission) and concentrating mainly on those who don't engage in risky sex seems like completely the wrong way to go about things. For a start, let's stop pretending that the majority of people are at risk of being infected sexually and find out why people engaging in low risk sex seem to be the largest contributor to Kenya's HIV epidemic.
The least we can ask of the Global Fund, then, is that even if they are not prepared to spend anything on non-sexually transmitted HIV, they should seriously consider targeting those who are genuinely at risk of sexual transmission: MSM and sex workers, and perhaps some others.
Monday, December 20, 2010
Mass Male Circumcision; a Motiveless Crime?
Some of the staunchest advocates of mass male circumcision (MMC) as a means of protecting men from infection with HIV, and even herpes simplex virus (HSV-2), have found that the operation is unlikely to have very much effect. Many years of 'research' has been carried out on how to ram MMC down the throats of male members of the Luo tribe in Kenya's Nyanza province.
There has never been much convincing evidence that MMC would be effective in the first place, but circumcision advocates don't seem bothered by that. And the more certain it is that MMC will not do any good, that it may even do a lot of harm, the more enthusiastic advocates become. In fact, this data was collected before large numbers of Luo men were circumcised (or were claimed to have been circumcised, actual numbers are hard to come by).
This particular piece of research found extremely high HIV (and HSV-2) prevalence; 17% among males and 26% among females. Rates for both viruses were similar for circumcised and uncircumcised males. Rates like this contrast strongly with those found in the rest of Kenya, with national prevalence standing at 6 or 7%. The second highest male prevalence rates, found among the Maasai, are about half those found among the Luo.
Those promoting circumcision have not explained the huge differences between tribes in HIV prevalence rates. There are even anomalies such as the extremely high rates among female Luhyas (12%) when rates among male Luhyas are relatively low (1.9%).
In short, HIV rates are high among the Luo, many of whom are not circumcised. But circumcised Luos have equally high HIV rates. So why insist that lack of circumcision explains why members of this tribe have such high HIV rates? And why insist on MMC when this is obviously not going have much positive impact on transmission rates and may have a negative impact?
The research also shows that people have been hoodwinked by the hype that MMC has received. Men think they are less likely to be infected with HIV if they are circumcised and women think circumcised men are less likely to be HIV positive. What most people don't seem to realize is that the 60% protection that circumcision arguably imparts requires that condoms are also used.
But if condoms are used, uncircumcised men are also protected. The operation is not only possibly useless and potentially harmful but it is also completely unnecessary, even for those who think it may protect them. They could just use condoms.
The research notes that "Uncircumcised men who preferred circumcision were more likely to report inconsistent or no condom use, describe sexual partners as ‘casual’, and report current/recent genital ulcerations" and that these men may 'self-select' for an MMC program. The authors see this as a good thing but I would question their analysis of this finding.
Other research suggests that many men and women think male circumcision will protect them from HIV and that they don't need to use condoms. Even people who can give the 'correct' answers to questions about HIV and circumcision, as a result of having them drummed into their heads, seem a little too anxious to embrace an intervention which is not well understood (by them or anyone else).
Recommending, and even carrying out, an operation that is clearly unnecessary and possibly hazardous sounds distinctly unethical. Failing to establish why HIV transmission rates are so high among the Luo after so many years of research is bad enough, but it certainly does not support the contention that what Luos need is MMC. Having said all that, I am unable to supply a motive for the behavior of circumcision advocates and would love to hear from anyone who could do so.
There has never been much convincing evidence that MMC would be effective in the first place, but circumcision advocates don't seem bothered by that. And the more certain it is that MMC will not do any good, that it may even do a lot of harm, the more enthusiastic advocates become. In fact, this data was collected before large numbers of Luo men were circumcised (or were claimed to have been circumcised, actual numbers are hard to come by).
This particular piece of research found extremely high HIV (and HSV-2) prevalence; 17% among males and 26% among females. Rates for both viruses were similar for circumcised and uncircumcised males. Rates like this contrast strongly with those found in the rest of Kenya, with national prevalence standing at 6 or 7%. The second highest male prevalence rates, found among the Maasai, are about half those found among the Luo.
Those promoting circumcision have not explained the huge differences between tribes in HIV prevalence rates. There are even anomalies such as the extremely high rates among female Luhyas (12%) when rates among male Luhyas are relatively low (1.9%).
In short, HIV rates are high among the Luo, many of whom are not circumcised. But circumcised Luos have equally high HIV rates. So why insist that lack of circumcision explains why members of this tribe have such high HIV rates? And why insist on MMC when this is obviously not going have much positive impact on transmission rates and may have a negative impact?
The research also shows that people have been hoodwinked by the hype that MMC has received. Men think they are less likely to be infected with HIV if they are circumcised and women think circumcised men are less likely to be HIV positive. What most people don't seem to realize is that the 60% protection that circumcision arguably imparts requires that condoms are also used.
But if condoms are used, uncircumcised men are also protected. The operation is not only possibly useless and potentially harmful but it is also completely unnecessary, even for those who think it may protect them. They could just use condoms.
The research notes that "Uncircumcised men who preferred circumcision were more likely to report inconsistent or no condom use, describe sexual partners as ‘casual’, and report current/recent genital ulcerations" and that these men may 'self-select' for an MMC program. The authors see this as a good thing but I would question their analysis of this finding.
Other research suggests that many men and women think male circumcision will protect them from HIV and that they don't need to use condoms. Even people who can give the 'correct' answers to questions about HIV and circumcision, as a result of having them drummed into their heads, seem a little too anxious to embrace an intervention which is not well understood (by them or anyone else).
Recommending, and even carrying out, an operation that is clearly unnecessary and possibly hazardous sounds distinctly unethical. Failing to establish why HIV transmission rates are so high among the Luo after so many years of research is bad enough, but it certainly does not support the contention that what Luos need is MMC. Having said all that, I am unable to supply a motive for the behavior of circumcision advocates and would love to hear from anyone who could do so.
Monday, November 8, 2010
NGOs Gagging for Sex
Spiked Online has an interesting article on NGOs in Asian countries who feel they are 'saving' people in the sex trade from exploitation. The problem is, those NGOs don't seem to want to know why so many adults would choose to do work that some consider to be inherently exploitative. The article points out that some workers came from far more exploitative industries, although the exploitation may have involved slave wages, a far lesser form of exploitation, it would appear.
There seems to be a lot of money available for NGOs who do this kind of work. On the other hand, there is not quite as much of the sort of headline-grabbing sexual exploitation going on as some would have us believe. Credible data is not one of the results of the large amounts of money being ploughed into the work these NGOs are doing.
The article finds that a lot of sex workers in Cambodia are former garment workers, people who choose to work in the sex industry rather than try to get by on impossibly low wages. So the NGOs are right, there is exploitation; it just doesn't involve sex. Perhaps the NGOs could redirect their efforts towards the garment factories, their rich owners, adequate legislation and enforcement or even the consumers in the rich countries that many NGO workers come from.
Here in East Africa, many people in the sex industry either tried working in highly exploitative export processing zones (EPZ) or various industries that pay so badly, there is little alternative but to find something to supplement incomes. In other words, sexual exploitation is not the only kind of exploitation they suffer. These EPZs are set up so that foreign industrialists can set up in developing countries and keep their costs as low as possible and thus provide Western countries with the cheap goods they crave.
Another exploitative industry is hospitality, where profits are generally unthreatened by high labor costs. Several sex workers I have met told me they tried to get work in hotels and it was made clear that they had to pay a bribe, using money or sex, to be considered for a job. Others had to pay, somehow, to keep their job, to get enough work to survive or to get promotion.
The Spiked article makes the point that people, adults, anyhow, can make up their own minds. They are not the mere victims they are often made out to be by some 'concerned' NGOs. This is quite true. But there also seems to be plenty of work that these NGOs could do if they are truly concerned about exploitation. Or does exploitation have to be sexual in order to be really worrying? The suggestion is that, no, it doesn't have to be sexual, but that's what the funders like.
A similar love for anything sexual also seems to dog HIV programing, with almost all prevention efforts being aimed at sexual transmission. Aside from this doing little or nothing to reduce non-sexual transmission, it doesn't appear to have had much impact on sexual transmission either. Billions of dollars have gone into programs that appear to target sex, rather than health. As a result, millions of people, particularly women and children, continue to be infected needlessly.
Objection to commercial sex work may be legitimate enough, but do those who object have an alternative in mind? Everyone can think of alternatives, but they are not viable in countries with very high levels of unemployment and underemployment, where the vast majority of people just get by and a lot don't even do that.
Every new, unemployed person, squeezing a few dollars out of some form of subsistance, results in less money for all those already struggling. Ironically, the effect of persuading a good many sex workers to give up their work and do something more 'conventional' would be to reduce the living that subsistence workers can make. And it will increase the amount of money that those still in sex work can make (unless sex work is supply drive, which seems unlikely).
If these NGOs don't address the real problems of lack of employment opportunities, exploitation in the work place, extreme poverty and the like, they will just be shuffling the problem from one group of people on to another. And addressing the real problems is no easy task. But things won't get any easier by wasting time with moral crusades and media titillation.
The Economist covers a similar theme and wonders why money is not spent on 'harm reduction', protecting sex workers from the risks they face, which are by no means limited to sexual risks. One of the main sources of stigma they face comes from the NGOs who claim to represent their interests. In addition to health services and condoms, sex workers need the protection of the law, especially from the police, who are among the many who stand to gain from the criminalization of sex work.
Again, this phenomenon is clear enough in East Africa, where people who think of themselves as 'clean living' fail to see that there are multitudes of people 'living on immoral earnings'. It's not just sex workers who do so. To evade exploitation by police, sex workers have to pay or otherwise bribe security people, bar, club and hotel administrations, 'minders' and anyone else happy to rely on the fact that sex workers are considered to be beneath contempt.
According to The Economist article, sex work tends to be conflated with human trafficking. This merely results in further exploitation of those involved in sex work, carried out in the name of 'zero tolerance', 'fighting crime', etc. NGOs operating like this are exploiting the very vulnerability of sex workers that they claim to be alleviating.
Much of the vulnerability of sex workers stems from the fact that the work is considered to be illegal, even where it is not outrightly prohibited by the law. NGOs would be far better advised to support sex workers than to oppose them, to help them gain the decriminalization they need. Without the protection of the law as a minimum, social problems relating to sex work will only get worse.
NGOs who wish to 'help' sex workers need to deal with the economic and social realities in developing countries. If they are opposed to exploitation, there is plenty of that, though it may not be sexual. And if these NGOs are motivated by some kind of moral repugnance towards sexual exploitation, they could direct it at those in the media and those in the donor community who appear to need sexual titillation in return for their support.
There seems to be a lot of money available for NGOs who do this kind of work. On the other hand, there is not quite as much of the sort of headline-grabbing sexual exploitation going on as some would have us believe. Credible data is not one of the results of the large amounts of money being ploughed into the work these NGOs are doing.
The article finds that a lot of sex workers in Cambodia are former garment workers, people who choose to work in the sex industry rather than try to get by on impossibly low wages. So the NGOs are right, there is exploitation; it just doesn't involve sex. Perhaps the NGOs could redirect their efforts towards the garment factories, their rich owners, adequate legislation and enforcement or even the consumers in the rich countries that many NGO workers come from.
Here in East Africa, many people in the sex industry either tried working in highly exploitative export processing zones (EPZ) or various industries that pay so badly, there is little alternative but to find something to supplement incomes. In other words, sexual exploitation is not the only kind of exploitation they suffer. These EPZs are set up so that foreign industrialists can set up in developing countries and keep their costs as low as possible and thus provide Western countries with the cheap goods they crave.
Another exploitative industry is hospitality, where profits are generally unthreatened by high labor costs. Several sex workers I have met told me they tried to get work in hotels and it was made clear that they had to pay a bribe, using money or sex, to be considered for a job. Others had to pay, somehow, to keep their job, to get enough work to survive or to get promotion.
The Spiked article makes the point that people, adults, anyhow, can make up their own minds. They are not the mere victims they are often made out to be by some 'concerned' NGOs. This is quite true. But there also seems to be plenty of work that these NGOs could do if they are truly concerned about exploitation. Or does exploitation have to be sexual in order to be really worrying? The suggestion is that, no, it doesn't have to be sexual, but that's what the funders like.
A similar love for anything sexual also seems to dog HIV programing, with almost all prevention efforts being aimed at sexual transmission. Aside from this doing little or nothing to reduce non-sexual transmission, it doesn't appear to have had much impact on sexual transmission either. Billions of dollars have gone into programs that appear to target sex, rather than health. As a result, millions of people, particularly women and children, continue to be infected needlessly.
Objection to commercial sex work may be legitimate enough, but do those who object have an alternative in mind? Everyone can think of alternatives, but they are not viable in countries with very high levels of unemployment and underemployment, where the vast majority of people just get by and a lot don't even do that.
Every new, unemployed person, squeezing a few dollars out of some form of subsistance, results in less money for all those already struggling. Ironically, the effect of persuading a good many sex workers to give up their work and do something more 'conventional' would be to reduce the living that subsistence workers can make. And it will increase the amount of money that those still in sex work can make (unless sex work is supply drive, which seems unlikely).
If these NGOs don't address the real problems of lack of employment opportunities, exploitation in the work place, extreme poverty and the like, they will just be shuffling the problem from one group of people on to another. And addressing the real problems is no easy task. But things won't get any easier by wasting time with moral crusades and media titillation.
The Economist covers a similar theme and wonders why money is not spent on 'harm reduction', protecting sex workers from the risks they face, which are by no means limited to sexual risks. One of the main sources of stigma they face comes from the NGOs who claim to represent their interests. In addition to health services and condoms, sex workers need the protection of the law, especially from the police, who are among the many who stand to gain from the criminalization of sex work.
Again, this phenomenon is clear enough in East Africa, where people who think of themselves as 'clean living' fail to see that there are multitudes of people 'living on immoral earnings'. It's not just sex workers who do so. To evade exploitation by police, sex workers have to pay or otherwise bribe security people, bar, club and hotel administrations, 'minders' and anyone else happy to rely on the fact that sex workers are considered to be beneath contempt.
According to The Economist article, sex work tends to be conflated with human trafficking. This merely results in further exploitation of those involved in sex work, carried out in the name of 'zero tolerance', 'fighting crime', etc. NGOs operating like this are exploiting the very vulnerability of sex workers that they claim to be alleviating.
Much of the vulnerability of sex workers stems from the fact that the work is considered to be illegal, even where it is not outrightly prohibited by the law. NGOs would be far better advised to support sex workers than to oppose them, to help them gain the decriminalization they need. Without the protection of the law as a minimum, social problems relating to sex work will only get worse.
NGOs who wish to 'help' sex workers need to deal with the economic and social realities in developing countries. If they are opposed to exploitation, there is plenty of that, though it may not be sexual. And if these NGOs are motivated by some kind of moral repugnance towards sexual exploitation, they could direct it at those in the media and those in the donor community who appear to need sexual titillation in return for their support.
Wednesday, August 25, 2010
Harm Reduction Needs to Start in Health Facilities
Now that PEPFAR (the US President's Emergency Plan for AIDS Relief) have revised their Bush era decision to refuse funding to harm reduction programs, the Kenyan government may also consider changing their policy towards intravenous drug users (IDU). According to the head of Kenya's National Aids Control Program, addiction will be treated as a health issue and needle exchange, methadone and condoms will provided for IDUs.
Although the contribution of intravenous drug use to Kenya's epidemic is currently estimated to stand at about 4%, this kind of exposure is a highly efficient transmitter of HIV. Heterosexual sex, on the other hand, is not such an efficient transmitter. In some countries, sex workers are only likely to die of Aids if they are also IDUs.
Commercial sex work can be one of the few ways to make enough money to feed a drug addiction. The drugs have to be paid for, but injecting equipment can be, and often is, shared. So a source of clean injecting equipment for IDUs could play a big part in reducing HIV transmission by this route. However, the decision to fund HIV programs that target HIV transmission among IDUs may also allow better estimates of their full contribution towards Kenya's epidemic. It may also allow a better evaluation of the part that commercial sex work plays in the epidemic.
Very few HIV positive IDUs are currently on antiretroviral treatment. Such treatment could significantly reduce sexual transmission of HIV, though it may not reduce non-sexual transmission so much. But giving IDUs better access to diagnosis and treatment should improve conditions for them and reduce further HIV transmission.
Sadly, the Kenyan police force may need more than a change in the law. As long as they and others can make money out of drug users, it's unlikely they will all turn into social workers overnight. Nor are NASCOP in a position to decriminalize drug use on their own. So let's hope decriminalization becomes a reality. If the administrators of PEPFAR can change their minds for ideological reasons, I'm sure the relevant people in the Kenyan government could change theirs for pragmatic reasons.
But any kind of re-evaluation of non-sexual modes of HIV transmission would be welcome in Kenya, in fact, in all African countries. If donors, governments, health professionals and other big players in the HIV scene start to think about highly efficient modes of transmission, as opposed to the low efficiency of most types of sexual behavior, ordinary academics, epidemiologists and others may eventually be allowed to research and publish data that currently appears to be deprecated (to put it mildly).
Those with the money, however they managed to get hold of it, decide how that money should be spent. There's little point in waving a lot of drug addicts in front of donors if those donors are opposed to working with drug addiction. With such restrictions lifted, who knows, drug addiction, and therefore HIV transmission among IDUs (and those they associate with), may turn out to be more common than previously assumed.
Perhaps donors and governments will eventually revise their attitude towards commercial sex work, especially in view of its interconnections with drug use. This could even lead to questions about exactly how much sex has to do with HIV when the far more likely transmitter is non-sexual.
And, it's a long shot, but if the HIV industry is willing to accept that some HIV is transmitted non-sexually, even among people who are said to have a lot of 'unsafe' sex, they may even wonder if ordinary people engaging in ordinary amounts of 'safe' sex are being infected non-sexually too.
Drug users are not the only people who use injecting equipment. More disturbingly, they are not the only people reusing injecting equipment. Some people get a lot of injections, because they are sick, pregnant, an infant, a sex worker, whatever. And in populations with high HIV prevalence, all of those people are at heightened risk of being infected with HIV, non-sexually.
Maybe we’ll live to see the day when sex is viewed once again as an aspect of health and life rather than as a spreader of disease. But first, we have to accept that poor health care can be a significant source of disease. Harm reduction programs, now that health care professionals and governments are allowed to talk about them again, need to start in health facilities.
Sunday, August 8, 2010
In the Absence of Evidence, Use a Shoehorn
According to an article entitled ‘Moulding Men You Can Count On’, “Research shows that men are the main drivers of the HIV epidemic. Men transmit HIV to women, who, in turn, can infect their babies if they fall pregnant.” But this is not something demonstrated by research. It is an interpretation of research that often purports to be well supported. While some men transmit HIV to women, the majority of HIV positive people in African countries are women. There is no evidence that there is a relatively small group of men who sleep with a relatively large group of women.
Of course, there are some men who sleep with a lot of women and some women who sleep with a lot of men. But that’s also the case in non-African countries, where HIV rates are very low. And women also transmit HIV to men. And men transmit HIV to men. The majority of new HIV infections in a country like Uganda are among monogamous and often married people. Also, many HIV positive people have a HIV negative partner.
Various shoehorning arguments have been advanced about men who have sex with men (MSM) also having sex with women. But the percentage of MSM in African countries is unlikely to be much larger than in non-African countries. And women are said to be more vulnerable for structural reasons, such as their relative inequality in society and in marriage. This may be true, but again, most new infections are in monogamous couples and the male partner is often not infected. Women do not become infected by having sex with uninfected men.
The shoehorning becomes more obtuse, racist and sexist. But in the end, the sort of rapid transmission of a virus that is difficult to transmit sexually, found in some African countries, is not explained unless unbelievable levels of unsafe sexual practices are hypothesized. Such levels are not borne out by evidence, but they seem to be believed by the HIV industry. As a result, sexual behaviour in African countries is targeted by almost all HIV ‘prevention’ programs. This has not worked, but the industry is wealthy and powerful enough to continue its deceit. And most academics in the field seem happy to go along with that.
So, not only would this assumed small group of men, who drive HIV epidemics, have to have sex with a lot of women to explain the number of women who are HIV positive, those men must also have had sex with an even greater number of women who were not infected. After all, the probability of infecting someone is lower than 1, thankfully. This is not to deny that there are many social problems, some of which may increase the transmission of HIV. All social problems should be targeted. But let’s not pretend that some of them are driving HIV epidemics when this is clearly not true.
The article correctly points out that no one, male or female, can assume that their partner’s status is the same as their own. But similar remarks apply to children. The mother’s status is not a reliable indicator of their children’s status. Nor is the children’s status a reliable indicator of their mother’s. There have been enough instances identified of discordant couples (where one member is HIV positive and the other is HIV negative). And there have been enough instances of infants and children being found to be HIV positive when their mothers are not.
There’s no great mystery about this. People can be infected with HIV through sexual intercourse with someone who is HIV positive; infants can be infected by their mother. But people can also be infected by unsafe medical, cosmetic or certain traditional rituals. People of all ages can undergo any of these, perhaps all of them. And, while sexual transmission of HIV is not very efficient, transmission through contaminated blood or through other bodily fluids can be very efficient.
The article is about targeting men, because many HIV programs don’t do this, or don’t do it very well. It is very worthwhile targeting men, but it would be far better if they were being supplied with correct and complete information. Men may react a lot better if they are not being accused or implicated in ‘driving HIV epidemics’. Some men engage in unsafe sexual behaviour, as do some women, all over the world. But these same people are entitled to know about other unsafe practices in order to be able to avoid both infection and transmission of HIV and other blood borne diseases. Equally, those who do not engage in unsafe sexual behaviour are entitled to know how to protect themselves, if they are HIV negative. And they are entitled to know how they may have become infected if they are HIV positive.
This program targeting men, and any other program that aims to reduce HIV transmission, needs to make it clear how HIV can be transmitted. People need to know how to protect themselves, completely. There is no point in telling them to reduce their number of sexual partners, have sex less, be faithful to their partner, use condoms and take any other precautions, while neglecting to tell them about non-sexual modes of transmission. Even people whose sexual behaviour is deemed to be risky also face non-sexual risks. Men who have sex with men and commercial sex workers, often thought to be at highest risk of sexual transmission of HIV, also risk being infected and infecting others non-sexually.
There is a lot of talk about ‘knowing your status’ but that’s not enough on its own. You also need to know how you became infected. Especially if your partner is not infected, because then you might have some explaining to do. The assumption that most HIV is transmitted sexually in African countries is one of the main sources of stigma. Men who are being targeted for HIV awareness training also need to know that being HIV positive does not mean you have been engaging in unsafe sex. Then, if their partner is found to be HIV positive, it is less likely that they will react violently. If people don’t know about non-sexual risks and hear about nothing but sexual risks, it’s hard to change the message later. It’s not surprising that people think all sorts of terrible things about a partner who has just been diagnosed as HIV positive when they themselves are HIV negative.
People need and are entitled to correct information, but also, complete information. Allowing them to assume that they are safe from HIV by taking all the recommended measures to avoid sexual transmission does not protect them from non-sexual modes of transmission. Failing to inform people about non-sexual risks is, effectively, luring them into a false sense of security. People will not take precautions against risks they don’t know about. Involving men is vital and the program in question must be applauded for that, but it must include information about non-sexual HIV transmission for two main reasons; to reduce transmission and to reduce stigma. Otherwise the program is as pointless as most of the others approved of by UNAIDS and the HIV industry.
Of course, there are some men who sleep with a lot of women and some women who sleep with a lot of men. But that’s also the case in non-African countries, where HIV rates are very low. And women also transmit HIV to men. And men transmit HIV to men. The majority of new HIV infections in a country like Uganda are among monogamous and often married people. Also, many HIV positive people have a HIV negative partner.
Various shoehorning arguments have been advanced about men who have sex with men (MSM) also having sex with women. But the percentage of MSM in African countries is unlikely to be much larger than in non-African countries. And women are said to be more vulnerable for structural reasons, such as their relative inequality in society and in marriage. This may be true, but again, most new infections are in monogamous couples and the male partner is often not infected. Women do not become infected by having sex with uninfected men.
The shoehorning becomes more obtuse, racist and sexist. But in the end, the sort of rapid transmission of a virus that is difficult to transmit sexually, found in some African countries, is not explained unless unbelievable levels of unsafe sexual practices are hypothesized. Such levels are not borne out by evidence, but they seem to be believed by the HIV industry. As a result, sexual behaviour in African countries is targeted by almost all HIV ‘prevention’ programs. This has not worked, but the industry is wealthy and powerful enough to continue its deceit. And most academics in the field seem happy to go along with that.
So, not only would this assumed small group of men, who drive HIV epidemics, have to have sex with a lot of women to explain the number of women who are HIV positive, those men must also have had sex with an even greater number of women who were not infected. After all, the probability of infecting someone is lower than 1, thankfully. This is not to deny that there are many social problems, some of which may increase the transmission of HIV. All social problems should be targeted. But let’s not pretend that some of them are driving HIV epidemics when this is clearly not true.
The article correctly points out that no one, male or female, can assume that their partner’s status is the same as their own. But similar remarks apply to children. The mother’s status is not a reliable indicator of their children’s status. Nor is the children’s status a reliable indicator of their mother’s. There have been enough instances identified of discordant couples (where one member is HIV positive and the other is HIV negative). And there have been enough instances of infants and children being found to be HIV positive when their mothers are not.
There’s no great mystery about this. People can be infected with HIV through sexual intercourse with someone who is HIV positive; infants can be infected by their mother. But people can also be infected by unsafe medical, cosmetic or certain traditional rituals. People of all ages can undergo any of these, perhaps all of them. And, while sexual transmission of HIV is not very efficient, transmission through contaminated blood or through other bodily fluids can be very efficient.
The article is about targeting men, because many HIV programs don’t do this, or don’t do it very well. It is very worthwhile targeting men, but it would be far better if they were being supplied with correct and complete information. Men may react a lot better if they are not being accused or implicated in ‘driving HIV epidemics’. Some men engage in unsafe sexual behaviour, as do some women, all over the world. But these same people are entitled to know about other unsafe practices in order to be able to avoid both infection and transmission of HIV and other blood borne diseases. Equally, those who do not engage in unsafe sexual behaviour are entitled to know how to protect themselves, if they are HIV negative. And they are entitled to know how they may have become infected if they are HIV positive.
This program targeting men, and any other program that aims to reduce HIV transmission, needs to make it clear how HIV can be transmitted. People need to know how to protect themselves, completely. There is no point in telling them to reduce their number of sexual partners, have sex less, be faithful to their partner, use condoms and take any other precautions, while neglecting to tell them about non-sexual modes of transmission. Even people whose sexual behaviour is deemed to be risky also face non-sexual risks. Men who have sex with men and commercial sex workers, often thought to be at highest risk of sexual transmission of HIV, also risk being infected and infecting others non-sexually.
There is a lot of talk about ‘knowing your status’ but that’s not enough on its own. You also need to know how you became infected. Especially if your partner is not infected, because then you might have some explaining to do. The assumption that most HIV is transmitted sexually in African countries is one of the main sources of stigma. Men who are being targeted for HIV awareness training also need to know that being HIV positive does not mean you have been engaging in unsafe sex. Then, if their partner is found to be HIV positive, it is less likely that they will react violently. If people don’t know about non-sexual risks and hear about nothing but sexual risks, it’s hard to change the message later. It’s not surprising that people think all sorts of terrible things about a partner who has just been diagnosed as HIV positive when they themselves are HIV negative.
People need and are entitled to correct information, but also, complete information. Allowing them to assume that they are safe from HIV by taking all the recommended measures to avoid sexual transmission does not protect them from non-sexual modes of transmission. Failing to inform people about non-sexual risks is, effectively, luring them into a false sense of security. People will not take precautions against risks they don’t know about. Involving men is vital and the program in question must be applauded for that, but it must include information about non-sexual HIV transmission for two main reasons; to reduce transmission and to reduce stigma. Otherwise the program is as pointless as most of the others approved of by UNAIDS and the HIV industry.
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