It's not Condoms that are Failing to Protect Against HIV, it's UNAIDS

[Cross posted from the Don't Get Stuck With HIV blog.]

At the beginning of this month, David Gisselquist took a careful look at UNAIDS' 'Modes of Transmission' model and found it seriously lacking, grossly overestimating HIV transmission among couples in long term relationships in Malawi. As a result of this flaw, the model gives results which appear to support the extremely racist view that most Africans in high HIV prevalence countries, male and female, engage in a lot of unsafe sex, and mainly sex with people other than their partners.

David shows how the Modes of Transmission model currently estimates that 81% of Malawi's 95,000 new HIV infections were accounted for by spousal transmission. If you remove the flaw, the percentage goes down to 20%, leaving 60% of all infections unaccounted for by the model (non-sexual transmissions from mother to child make up much of the remainder). How were all those other people infected, including the women who are said to have infected their babies?

It is very likely that a substantial number of HIV infections in Malawi and other high prevalence countries are a result of non-sexual transmission, such as through unsafe healthcare, cosmetic procedures and traditional practices. The much lauded 'ABC' (Abstain, Be faithful, use Condoms) approach to HIV prevention does not work, not because many Africans actually live up to the stereotypical 'all men are bastards, all women are hapless victims', but because HIV is not always transmitted through heterosexual sex.

Consider condoms, which are a great technology for reducing unplanned pregnancies, many sexually transmitted infections and sexually transmitted HIV, through anal and vaginal intercourse. But a number of surveys have found that HIV prevalence is very high among those who use condoms. Indeed, prevalence is often higher among those who at least sometimes use condoms than among those who never use them. The following chart is from the relevant Demographic and Health Survey for four countries.

In some cases, HIV prevalence is 50% higher among those who sometimes use condoms than among those who never use them, sometimes 100%. Shocking? Only if you think HIV transmission in high prevalence African countries is all about sex. Consider another set of figures, this time for condom use at last sexual intercourse in past 12 months. The figures for those who have not had sex in the past 12 months also raise questions (data from DHS surveys). You could suggest that people are not honest, or that people who are infected are 'abstaining', but it is far more vital to figure out exactly how people are being infected in order to prevent further infections.

Why are HIV prevalence figures so much higher among people who say they sometimes use condoms? I can only tell you what I think; condom use is completely irrelevant to non-sexually transmitted HIV. That sounds obvious, but UNAIDS insist that almost all transmission is through heterosexual sex, yet they stand by figures like these. It is not possible for HIV prevalence to be so much lower among those who never use condoms if almost all HIV transmission is sexual. But there may be an explanation for why those who sometimes use condoms seem so much more likely to be infected.

HIV prevalence is often highest among wealthier, urban dwelling, employed, female, better educated people who live in wealthier countries that have reasonable access to reproductive healthcare services, a relatively low population density and sometimes a higher urban population (but not always). People who answer that description, people who can tick at least some of those boxes (some of the factors are interdependent), it seems, are also more likely to use condoms.

So it is not a case of people with the above characteristics using condoms, yet still being more likely to be infected with HIV, but rather a case of those same people being more likely to be infected with HIV through unsafe healthcare or some other non-sexual route. Once you challenge the sexual behavior paradigm the rest is clear: condoms are irrelevant to non-sexual HIV transmission. It only sounds unintuitive if you keep clinging to the sexist, racist and extremely dangerous reflex about sexual behavior, so beloved by UNAIDS, WHO, CDC, PEPFAR, the Gates Foundation and various universities that have been prominent in the HIV industry.

Given what we so often hear about HIV being inextricably linked with poverty, unemployment, lack of education, isolation, poor access to health services, etc, it is worth emphasizing that the virus may often be more closely linked to the opposite of these factors. Of course, all of these factors are abhorrent and it should be the aim of every wealthy country to ensure that such conditions are alleviated. But if HIV is being transmitted through unsafe healthcare and other routes, all healthcare development must be SAFE healthcare, all HIV education must include information about non-sexual transmission, all employment 

and environments must exclude risks of bloodborne transmission of HIV, as much as possible.

So first we need to recognize that HIV is not solely transmitted through 'unsafe' sex and that it can be transmitted, perhaps far more easily, through unsafe healthcare, cosmetic procedures and traditional practices. ABC 'strategies' do not work because HIV transmission is not all about sex, not because Africans are too careless, promiscuous or ignorant (or even 'disempowered') to follow its patronizing advice. Safe sex has its place, but safe healthcare is a far more urgent issue in high HIV prevalence African countries right now. It's not condoms that are failing to protect people against HIV, but the intransigence of UNAIDS and the rest of the HIV industry.

Vatican and UNAIDS Agree to Appear to Disagree

It seems that UNAIDS and the Vatican are sort of agreeing about condoms. UNAIDS haven't managed to persuade very many people to use them frequently and consistently enough to reduce sexually transmitted infection rates (STI) or unplanned pregnancies.

And the Vatican doesn't care whether STI rates or unplanned pregnancy rates are reduced as long as no 'sins' are seen to be committed in the process. But in most Catholic countries, especially rich ones, people take little enough notice of the preachings of the church.

The two institutions have a lot in common. They are both massively wealthy, unelected and virtually unaccountable, packed with some of the most educated people in their field, slow to change and often utterly oblivious to what goes on in the outside world.

The invitation of Dr Michel Sidibe, executive director of UNAIDS, to speak at a conference at the Vatican is seen as significant because the Vatican "usually only invites like-minded outsiders to its conferences and UNAIDS has not been like-minded on this issue at all".

I think that's an exaggeration. Sidibe may have come down on the side of condoms and stressed abstinence and marital fidelity a little less, while the Vatican has stressed abstinence and marital infidelity more and appeared to rail against condoms.

But both parties wish to influence the sexual behavior of poor people and seem hell bent on doing so. Both Sidibe and the pope know that talk about abstinence and marital fidelity are just talk. So far, UNAIDS have made do with putting a brave face on the results of their 'prevention' programs and the Catholic church has long had to put up with keeping the lid on reality.

Let's face it, neither institution has really aimed to reduce HIV transmission very convincingly. Both have done everything in their power to protect their own interests, although those interests are not always completely clear.

In truth, condoms are about all we have to reduce sexually transmitted HIV. There is a lot of talk about other measures, microbicides, pre-exposure prophylaxis, treatment as prevention, circumcision and probably a few others. But all of these are recommended in conjunction with the consistent and correct use of condoms.

Catholics have long ignored the pope's pronouncements about certain things, including contraception, abortion, homosexuality, pre-marital sex and much else. Even many of the popes own leaders have been shown to enjoy a varied sex life, even if their ways of expressing their sexuality might not be so popular among their followers.

If the technocrats and multinationals are even close to being right in claiming that one or several of their offerings will one day significantly reduce HIV transmission, at least in certain contexts, the two mammoths may even be able to publicly agree on things, about condoms, health, even sex.

That would be interesting because neither party would end up being able to control people's sexual behavior in the ways they might wish. If any of these technological solutions can reduce HIV transmission, any incentive to use condoms or adopt any of the other strictures of 'safe sex', imagined or otherwise, will disappear.

I don't think anyone seriously believes HIV will just be wiped out in the forseeable future. Sadly, HIV transmission is going to continue to be high enough to infect huge numbers of people, but mainly in developing countries.

There is a lot of enthusiasm for something that looks like a solution, preferably just one single measure, rather than a combination of measures. Sidibe calls 'treatment as prevention' a game-changer, but it might also result in the almost total irrelevance of these two vast institutions.

Now is not the time to start backtracking on condoms. HIV is a matter of health, something neither of these institutions know anything about. We badly need an institution that can represent the health related interests of people, especially poor people living in developing countries. We don't need any more vested interests stealing the health agenda. So let's kiss the Vatican and UNAIDS goodbye and start working on HIV.

If Maternal and Child Health is Bad, Family Planning = Large Families

Would having a vasectomy make some men more likely to have unprotected sex? If they see contraception as just a protection against HIV (and perhaps other sexually transmitted infections), the vasectomy shouldn't, logically, result in a reduction in condom use. But I suspect it would be a good excuse for not using condoms.

If they see condom use and/or vasectomies as a means of reducing unplanned pregnancies, having a vactomy could well result in men having unprotected sex. They could see condoms having a dual purpose, but many HIV prevention and other types of health programs have made little effort to emphasize this dual purpose.

If male circumcision was also involved, how would that affect condom use? Of course, mass male circumcision campaigns do drone on about having to use condoms for circumcision to be effective. But I don't see many men getting circumcized if they don't think they can reduce their condom use, perhaps even dispense with them altogether.

If programs that aim at reducing heterosexual HIV transmission are combined with programs that aim at reducing a country's population, this could result in a very mixed message indeed. Who is going to undergo both circumcision and a vasectomy and still use condoms?

If circumcision in conjunction with condom use is intended to reduce sexual HIV transmission, this sort of program might best be kept separate from a program that aims purely at population control.

Besides, people who are not in a position to, or don't see themselves as being in a position to make family planning related choices that we in the Western world take for granted, may require a more subtle approach than 'offering' them vasectomies.

There must be a lot more to family planning than merely reducing the probability of conception in as many ways as possible. This smacks of the eugenicist subtext that seems to be hidden in much of the public health programs one hears about in developing countries.

Apparently Rwanda is combining its population growth program with its circumcision program, which is intended to reduce HIV transmission. Yet, the respective merits of each strategy, circumcision, condom use and vasectomies, are themselves matters for debate.

There is little doubt that correct and consistent use of condoms plays a large part in reducing unplanned pregnancy. But will people continue to use them if they think there is an alternative, or if they take care of unplanned pregnancy?

But it is far less clear that mass male circumcision has a significant impact on heterosexual HIV transmission outside of (relatively) carefully controlled trials. And even those trials only claim that circumcision reduces female to male transmission, which is a lot less common than male to female transmission, which it may even increase.

And a vasectomy may well reduce conception, perhaps even eliminate it completely. But the ethics of encouraging large numbers of people to have vasectomies, perhaps young men, should be considered carefully. And maybe those advocating the combination of all three should also look at the potential incompatibilities involved.

Programs designed to, or even programs that happen to reduce conception need to be accompanied by programs that aim to improve health services and even health education, nutrition, water and sanitation, working condititions, living conditions and everything else that make up the determinants of health.

Rwanda still has high infant, under five and maternal mortality. Life expectancy is low and most premature deaths are due to treatable and preventable conditions. Even HIV positive people tend to die of treatable and preventable conditions. Under such circumstances, the only viable form of family planning is to have big families.

Health programs that ignore the broader determinants of health will have little positive impact and may do a lot of damage. And the combined contraception/HIV reduction/vasectomy approach suggested for Rwanda sounds entirely unethical, as well as ineffective.

Pope Makes Stupid Comments; Some People Listen

The Pope and his merry gang are tying themselves in knots again about things they know little of. They are not experts in sex, only in denying that it occurs. Outside of ostentatiously religious circles, sex is just one type of human behavior, it's certainly not an act of gross immorality. It's a highly significant type of human behavior, but it dates back long before Christians decided to prognosticate about it.

If I was sick, suffering from any disease, HIV being just one, I certainly wouldn't ask the Pope's advice on how to live my life, how to avoid transmitting the disease, etc. And if I wanted to avoid HIV, or any other disease, I wouldn't aks the Pope for advice either. Because the advice I would get would be wrong.

Not that the advice you'd get from UNAIDS or many other institutions would be any better. They would all lecture you on sex, safe and unsafe, and they would probably tell you that no sex at all is the best thing. But not having sex will not protect you from HIV, especially in high prevalence countries. And practicing safe sex will not either.

Time after time, research has shown that people who have no sex or no unsafe sex are as likely to be HIV positive as those who have lots of sex or have unsafe sex most of the time. Sometimes, they are even more likely to be HIV positive. The connection between HIV and sex is tenuous.

This is not to say the connection does not exist. Certain kinds of sex are very dangerous, such as anal sex. Certain sexually transmitted infections (STI), very common in some countries (developing and developed), highly transmissable infections, increase the risk of transmitting or of contracting HIV. But the probability of transmission through heterosexual sex is generally low.

True, STIs can be very common in some African countries. But exceptionally high rates of easily treated sexually transmitted diseases is not a sign that people there have lots of sex, or lots of unsafe sex. It is a sign that the health services are in disarray. Many people hardly ever visit a health facility and many of those who do are as likely to be infected with something they don't already have as be cured of something they do have.

In addition to the risk of being infected with HIV and other diseases in hospitals and other health facilities, people even face risks if they go to a hairdresser, a tattoo artist or a pedicurist. UNAIDS and other institutions who are obsessed with others having sex don't want to admit it but these are far more efficient transmitters of HIV than sex.

Tanzania is, according to some figures, roughly divided into three in terms of dominant religious. About one third each are Muslim, Catholic or some kind of non-Catholic Christian. HIV rates are often (though not always) lower among Muslims. But rates are very similar among the other two religions.

Similar remarks apply to Kenya and some other countries. For all their posturing, Christians, Catholic or otherwise, are no less likely to be HIV positive, to suffer from high rates of other STIs, to engage in sexual behavior considered to be unsafe, to circumcise their daughters, to beat their wives and generally indulge things that are considered to be 'unchristian'.

The fact is, many people say the right things, or what they consider to be the right things, but they do just what they want to do. So shouting about whether condoms and contraception are wrong or right, for most people, is hypocritical and potentially dangerous. There is a vast unmet need for contraception among women in developing countries.

These 'Christians' would be better advised to figure out how to change the kinds of behavior that results in some of the worst social and development problems. They could even spend a bit of time considering how to reverse the levels of gender inequality that they have spent centuries building up because that is behind some of the biggest threats that people face, especially women, mothers and girls.

Every time an article like this is published, the irrelevance of Popes, priests and religions are shoved down our throats. But when these people and institutions stand by while others become infected with a debilitating and deadly disease, it's time to tell these overfed fools where to stuff their advice. If I thought the churches had something valid to say about morality, I might listen, but they don't.

Circumcision: 1.1 Million Kenyans Tricked Into Being Human Guinea Pigs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Swaziland Takes Half a Step Towards Eradicating HIV

According to IRIN's PlusNews, Swaziland is to dump its ABC approach HIV prevention (Abstain, Be faithful and use a Condom). Swaziland has the highest prevalence of HIV in the world. The article states: "experts are still at a loss as to why Swazis have resisted all attempts to change the behaviours that put them at risk from the virus." But they needn't be puzzled. ABC hasn't worked anywhere. It's just that Swaziland is the first country to publicly admit it.

Don't be fooled by all the articles about Uganda working magic in the 1990s using ABC to reduce HIV prevalence. The approach didn't exist in Uganda in the 1990s and HIV prevalence was never even as high in Uganda as most of these articles say. Prevalence did reach very high levels in the country and they are low now, that's true. But many strategies were employed to reduce HIV transmission and the main reason why prevalence dropped so quickly in the 1990s is because death rates were very high. A similar pattern occurred in Kenya somewhat later, which took the Kenyan government by surprise as they hadn't even got around to admitting that there was a HIV epidemic in the country.

While recognizing that ABC is not working in Swaziland, Dr Derek von Wissell, director of the National Emergency Response Council on HIV/AIDS is still convinced that "behaviour is what has to change". He then turns his attention to men, pointing out that 70% of men are "free agents", to whom being faithful does not apply. This is supposed to explain why HIV prevalence is 38% among girls in the 20-24 age group?

There is something very unconvincing about this explanation. Unless the majority of sexually active women are having a lot of unprotected sex with a small number of men, we really don't have any idea where all these infections are coming from. In order to infect someone with HIV, a man needs to be HIV positive. In fact, he also needs to have sex with each woman quite a number of times, statistically. If Dr von Wissell is thinking straight, there is a small number of men who need to be identified and given some good advice, quickly. Never mind targeting sexually active women.

But I don't think the man is thinking straight. His thinking, like that of most thinking throughout the HIV industry, is skewed by the 'behavioral paradigm', the belief that almost all HIV is transmitted through heterosexual sex in African countries. To hold this belief, you need to think that, sexually, Africans are different from people from other continents. They have a lot more unsafe sex with far more partners than those in other continents. Also, the women are particularly prone to having unsafe sex, lots of it, with a certain group of highly sexually active, HIV positive men.

Of course, these beliefs are just prejudices, there is no evidence for them. On the contrary, there is plenty of evidence that some people in all countries have lots of sex, even unsafe sex. But most people don't. Yet, in some African countries, HIV prevalence is so high that almost every sexually active woman can be considered lucky to remain uninfected. Swaziland, in particular. If you stick fast to your prejudices, you might wonder who these evil men are, you might even wonder about why the majority of women take such stupid risks. But if your approach to reducing HIV transmission is so influenced by prejudice, you may not be bothered by any glaring irregularities.

The lessons that the HIV industry steadfastly refuse to learn are that, one, you can't just legislate for (or against) certain kinds of sexual behavior, despite decades of evidence of this from the population control brigade. And two, not all HIV is transmitted sexually. If von Wissell wants to "challenge conventional thinking" and to avoid slavishly following what went before, he would want to go a little further than uttering soundbites about needing to find new ways to prevent infections. He could start by looking at how HIV is being transmitted, how it is actually being transmitted, not how the HIV industry says (and really wants to believe) it is being transmitted.

Even allowing a very high probability of HIV transmission per sex act, you would have to believe that Swazi women have a lot of sex with a lot of different partners to explain current prevalence rates. Coupled with that, you would have to believe in that small bunch of HIV positive men, who get to have sex with far more than their fair share of women. In days gone by, all sorts of myths were dreamed up to explain pregnancies that shouldn't have occurred, such as seals appearing as men and then disappearing again. But we don't need to resort to such myths any more. It's time for the HIV industry to wake up. It's time to admit that non-sexual HIV transmission plays a part in hyperendemic countries such as Swaziland and to investigate modes of transmission properly.

ABC doesn't work; it has never worked; it will never work. Good sex education, as opposed to obscure platitudes and moral cant that is completely ungrounded in any reality, would be welcome. Children in African countries are in bad need of any kind of education; but general education is a prerequisite to sex education. Education about and access to condoms would also be helpful, in many ways. But no approach to HIV prevention that assumes the truth of the behavioral paradigm will eradicate HIV. Swaziland has made the first half step. Let's hope the HIV industry doesn't interfere this time.

Political and Religious Leaders Overseeing the Spread of HIV

There's an interesting article on Aidsmap.com about how Ugandans who think they may be HIV positive are less likely to refer other family members for HIV testing. In a survey, people were asked before testing if they thought they were likely to be HIV positive. A majority said they thought they were likely to be. Of course, only some of them were. But most of those who are HIV positive in the country do not know their status. This doesn't bode well for a country that is said to have been so successful and progressive in its fight against the disease.

The very people who are most likely to be HIV positive are least likely to go for testing. So you would think that the Ugandan government would aim to target these people, make it easier for them to get tested, increase access to HIV facilities, reduce discrimination and stigma. Instead, the government is going in the opposite direction, trying to whip up anti gay feelings and making such strong threats against people even suspected of being gay that most people will be less willing to find out their HIV status, whatever their circumstances.

The Bahati Bill will make a lot of people avoid even discussing HIV or sexuality because if someone is found to be gay, HIV positive and sexually active, they will face the death sentence. In order to cover up their sexuality, many gay people are said to have heterosexual relationships, even to marry a heterosexual partner. Their partner will even face a lengthy prison sentence for not reporting that they were married to a gay person. Currently, only an estimated one quarter of HIV positive people know their status. If this bill becomes law, that figure should go down even further.

Some leading American Christians are said to be behind Bahati's bill. But the Catholic church is equally adamant that condoms shouldn't be used to prevent unplanned pregnancy, HIV or other sexually transmitted infections. They even lie about the effectiveness of condoms, which would seem to be in breach of the ninth commandment. But as far as they are concerned, it is 'artificial contraception', and therefore immoral. The use of condoms is currently being debated in The Philippines, where HIV prevalence is low, but rising.

You would think that political and church leaders would aim to reduce transmission of HIV and to stamp out stigma and discrimination. But, on the contrary, they seem to be against any measures that target some of the most significant channels to HIV infection. We must look beyond political and religious leadership if we are to have any hope of making progress in the fight against HIV.

Kenyans Don't Need Rights, Especially if They Are Women

The Kenyan MPs reviewing the draft constitution have decided that women will not have equal rights to men in marriage. They don't at present, so no change there. And a big missed opportunity in the fight against domestic violence, family impoverishment and indeed, the spread of HIV and other sexually transmitted infections (STI), along with unplanned pregnancies, including those among women who are HIV positive.

These extremely well paid MPs have decided to exclude much in the constitution that relates to rights and the role of civil society. This includes religious groups (and the Kenyan National Commission on Human Rights), so I'm sure the MPs will be persuaded to change their minds about the former! But Kenyans certainly, these MPs feel, don't need rights to water, housing or food (or social security, health, founding a family, safe environment, access to quality goods or efficient administrative action). It could be wondered what rights Kenyans are deemed to be entitled to by these (Kenyan) MPs.

One of the reasons that the use of condoms for reducing the spread of HIV, STIs and unplanned pregnancies has not been too successful is that women say they don't have the option to refuse to have unprotected sex with their husbands or partners. Effectively, they don't have the option to avoid becoming pregnant, even when they don't want more children or when they know they or their partners are HIV positive.

The Christian churches, the ones whose part in running the country may or may not be threatened by this constitutional review, of course, object to the use of contraception. The fact that it could prevent all sorts of social problems, such as the ones mentioned above, is irrelevant. Harm reduction will probably never cut any ice with Christian dogma. But it is unlikely that women's rights will fare any better in the ultimate male dominated institution.

However, on the insistence of the same Christian churches, the controversial paragraph that mentions the right to life without stating when life begins has been altered to stipulate that life begins at conception. Are all Kenyans Christians? Clearly not, but some vocal sectors of the civil society that these MPs seem to want to silence appear to have a lot more say in the new constitution than others.

Abortion is already illegal in Kenya. With very few exceptions, the hundreds of thousands of abortions that take place in Kenya every year are, therefore, unsafe. These unsafe abortions contribute to the maternal death rate of 30% and an estimated 2000 women die every year from unsafe abortions.

So the Christian churches are interested in the right to life of the unborn, but they don't seem to be so interested in the right of women to choose whether to become pregnant or even to choose who can make them pregnant or when. Women who know their partner or husband is HIV positive do not have the right to refuse to have sex or to insist on the use of a condom. Why are these Christian churches not as concerned about the rights of the very women who are expected to carry, give birth to and raise children where they do not choose to, perhaps because they or their partner is HIV positive?

A canon who was interviewed about this matter said that 'pregnancy is God's design' and that men and women are 'responsible to control themselves and engage in sex as a husband and wife', which, if you are a Christian, may well be true. But is the canon not aware that a lot of sexual activity doesn't take place between husbands and wives, that a lot of people have sex with people other than their husbands and wives, that some people don't get to choose when, where and with whom they have sex? The Christian churches, of all churches, should be aware of things like this.

If the Christian churches wish to oppose the use of contraception and a woman's right to choose, they need to pay some attention to the rights that women are currently being denied. Because it is in part the denial of these rights that is giving rise to huge numbers of unplanned pregnancies in the first place. If they sincerely want to reduce unplanned pregnancies, transmission of HIV and other STIs, sexual and gender based violence and other social problems, they would need to reconsider their position on contraception, for a start. If they are unable or unwilling to do that, these churches will find their relevance to the majority of Kenyans, especially poor Kenyans, diminishing as quickly as it has done in Western countries over the past few decades.

IYAP Kenya's New Blog

Photo: The strong wind that whips up the dust blows for much of the year and residents seem oblivious to it.

Isiolo Youth Against Aids and Poverty (IYAP) now have a blog, so you will be able to follow their activities as they continue to provide their services and introduce new services and facilities.

This week, the IYAP team spent most of the week operating their mobile clinic on the streets in and around Isiolo. At present, the weather is dry and very windy. So there is a cloud of reddish dust everywhere and everything quickly gets covered. But this hasn't put the team off and they tested over 250 people over four days.

A few months ago, IYAP were wondering how they would manage to raise money to continue their activities. But recently, Liverpool VCT (the organisation that trains most of Kenya's voluntary counsellors) have agreed to provide them with payment for the testing work they do and to help them meet some of their other costs. This will allow them to achieve their objectives and the team has breathed a big sigh of relief.

In the next few weeks, IYAP will be finding out what they can do with a blog and they will be launching a small, hosted site, displaying their contact details and the like. I'll make an announcement here when the site is available.

The Many Uses of Condoms

Sometimes the use of condoms to prevent infection with HIV is emphasized to such an extent that their use to prevent other sexually transmitted infections (STI) and to prevent unwanted and unplanned pregnancies is forgotten. Many STIs are easier to contract and transmit than HIV, some are difficult to treat and some increase the risk of being infected with or of transmitting HIV.

The consequences of contracting STIs other than HIV can be grave. In addition to serious illness, some STIs also affect fertility. But the consequences of unwanted or unplanned pregnancies can often be more serious, especially for younger people.

Many women who get pregnant unintentionally try to terminate the pregnancy. This is illegal in a lot of countries so they must resort to untrained abortionists or to carrying out the abortion themselves. The result can be injury, reduced fertility or death.

Many women, more than half a million a year and mainly in developing countries, die during pregnancy and childbirth. Some of them may have tried to terminate the pregnancy but there are all sorts of complications that can result in maternal death. Most of the deaths could have been averted with better and more accessible health services but also, many of these pregnancies could and should have been averted.

Certain religious and political groups have objected to the use of contraception and even to sex education. Others object to sex education for young teenagers. They feel that ready availability of contraception and widespread knowledge about sex only promotes promiscuity. However, there is plenty of evidence to show that these claims are unfounded. On the contrary, children who get comprehensive sex education are more likely to delay their sexual debut and more likely to use contraception.

Older people, married or single, need information and advice about sex, sexuality and family planning too. They need access to health services, contraception, etc. But more importantly, they need to be empowered to the extent that they are able to use contraception, whether it is to prevent conception or to avoid HIV or other STIs. Too many people say they didn’t know about contraception (or even about sex!) when they became sexually active. By the time they find out it can be too late, they may already be pregnant or already infected with an STI.

A lot of HIV money goes into ‘treatment and care’; but this really means that a lot of money goes into drugs. You need more than drugs to treat people suffering from a chronic illness like AIDS. Similarly, a smaller but still considerable amount of money goes into preventing mother to child transmission (PMTCT), also called vertical transmission. This also involves the use of drugs but again, it takes more than drugs to identify HIV positive mothers, to monitor them through pregnancy and delivery and then to monitor and care for the child.

It is estimated that 900 babies a day are born with HIV in developing countries because health services are not reaching women or because those health services are simply inadequate. Kenya, Tanzania and Uganda account for a large percentage of this figure. Pregnant women need to be tested and followed up, as do their children; drugs alone are not enough.

But to return to the condom and family planning point, many of the women giving birth to HIV positive babies didn’t want to get pregnant in the first place. Some hadn’t planned to get pregnant for all sorts of reasons, but some wanted to avoid pregnancy because they knew they were HIV positive. So, even many instances of vertical transmission could be averted by the use of condoms and other family planning techniques.

PMTCT, better maternal health and child health and many other health areas are compromised by poor health systems, shortages of trained personnel, low availability of the most appropriate drugs, etc. But maternal deaths, both from unsafe abortions and other causes, as well as vertical transmissions of HIV, could be reduced by the relatively cheap strategy of family planning.

Why throw large amounts of money at intractable problems when you could avert many of those intractable problems using relatively small amounts of money?

As always, the message from this blog is that HIV is serious. But there are other serious issues that people in developing countries face. Crucially, if some of these issues got a little more attention the question of HIV, in at least some cases, would not even arise.

Last Night, Condoms Saved Many Lives

IRIN (Integrated Regional Information Networks) had an article recently about Tanzanian bars and nightclubs getting condom vending machines soon. These machines would be placed in toilets as part of the national HIV prevention programme.

From reading HIV literature over the years, you would have thought there would already be dispensers in all bars, clubs, restaurants, hotels and anywhere else possible. But that is not the case. I have stayed in over 50 low budget hotels, eaten in over 100 restaurants, drunk in nearly as many bars and been to plenty of nightclubs and other places where people gather. And very few of them had an obvious supply of condoms.

Occasionally, when you are leaving a nightclub or late opening venue, you will find an enterprising stallholder outside, selling condoms. A little more frequently, you will see a box of condoms or even a selection of brands behind bars. I have little doubt that if you asked in some places you would get condoms.

Recently I stayed in a hotel and happened to open a drawer to find over 100 unbranded (donor supplied) condoms in an unmarked bag. Wonderful, except that they were manufactured in 2004 and will all expire in August.

But the problem is that people often don’t ask for condoms, for various reasons. And I’ve tried asking in some places, without success. As a result, people can be without condoms when it is too late to turn back. Or they are stuck with a vendor who only has expensive brands, so they don’t bother.

Condoms are too important to leave to chance. It’s true that they are an individual’s responsibility. But not everyone thinks of them at the right time; you can be taken by surprise and not everyone is as responsible as they should be. The Tanzanian programme is starting in Dar es Salaam, the commercial capital. But this is one place where you are much more likely to be able to find condoms, especially late at night. Let's hope the programme moves away from the capital to where the need for condoms and condom related education is far more urgent.

A young man who works for a HIV/Aids related community based organization recently told me that he thinks the only thing standing between Kenya and a far more serious HIV epidemic is condoms. He is a Muslim, a faith opposed to the use of condoms. But he works with people who are poor and marginalized. He knows a lot about why HIV spreads and he knows a lot about preventing it from spreading further.

It's not enough for people to be able to see the numerous signs and billboards about HIV and condoms, they need to be able to see the condoms, they need to know where to get them. And the times and places people are most likely to need condoms are no secret. People go to bars, clubs and other places to meet up with other people and have fun. Sometimes having fun involves having sex. Denying that this happens or arguing that it shouldn't happen is not going to prevent transmission of HIV, other sexually transmitted infections or unplanned pregnancies.

A reliable and accessible supply of condoms should become part of the country's national infrastructure. Yet, you still come across people who say they don't see them as much any more or you don't hear about them as much or they subscribe to one of the many myths about condoms not working or having holes in them that let viruses through. They do not have holes in them and they do work.

Of course they are not 100% safe. People say the only thing that is 100% safe is abstinence. The problem is that abstinence does not always work. People can have the best intentions but find themselves in a position where they are unable or unwilling to keep to them. The decision to abstain does not remove the possibility of circumstances and temptations.

I hope Tanzania and other African countries with a HIV epidemic, 'serious' or otherwise, make condoms more obviously available. This is one of the most important steps towards reducing transmission of HIV, sexually transmitted infections and unplanned pregnancies. To those who think that to promote condoms is to promote promiscuity I would say this: some people are promiscuous and until there is a feasible means of reducing promiscuity, condoms are one of the few things they have got to protect themselves from becoming infected and from infecting others with sexually transmitted infections.

Is the Catholic Church Afraid that Condoms May Work?

Recent research into condom use by adolescent males in Nairobi, Kenya, shows that the majority of participants in an online HIV awareness project did not use condoms the first time they had sex (69.9%). About half used a condom the last time they had sex but only one third use condoms most or all of the time.

Over 85% of these respondents were Christian; over two thirds were from middle or high income households; they were all attending secondary school; they were aged over 15 but the average age at first sex was just under 13 years old; nearly three quarters had already had 2 or more sexual partners.

It’s not as if we needed evidence that young people have sex, unsafe sex or sex at a very young age. We can fool ourselves that education is the key to preventing or reducing this sort of behaviour, but we have known for a long time that education on its own has little effect on sexual behaviour. Nor does wealth guarantee later sexual debut or safer sexual behaviour; the contrary may be more accurate.

Those who think that sex education is not appropriate for young people need to bear in mind what age many young people are when they start having sex. If they think sex education is only appropriate for those in their later teens, they will be too late for many.

It is also a mistake to think that children in their early teens do not need to know about condoms. Teenagers who have begun their sex lives without using condoms are less likely to use them later on. But those who use condoms the first time they have sex are more likely to continue doing so on all or most occasions. Learning about safe sex and condoms early on is a good thing.

Teaching children about abstaining from sex or delaying sexual initiation is also a good thing. Those who start sex at a later age are more likely to use condoms and are likely to behave more responsibly if they have received a good sex education. But if you teach children about abstaining from sex you need to tell them what sex is. They need to know many things so this is also a good time to tell them about condoms. They need to know about sex in order to abstain or even delay their sexual debut. If they don’t know much about sex, they will not know what to abstain from of what to delay.

The Catholic Church has a time honoured way of dealing with things that don’t fit its purposes (whether they be doctrinal, political, economic or whatever else): they say nothing or they lie. The church leader’s recent outburst about condoms making the HIV epidemic worse has been treated to amendments by those who surround him and he has done nothing to set the record straight. Perhaps in his eyes the record is already straight.

Since the HIV epidemic started, the Catholic and other Christian churches have done everything possible to frustrate the attempts of health professionals and others to prevent the spread of HIV, sexually transmitted infections (STI) and unwanted pregnancies. They have lied and pontificated about an interpretation of Christian morality that would see people suffer and die rather than ‘sin’. Even those who don’t do the sinning must suffer and die rather than allow ‘sin’ to occur.

Respondents in the survey hold views that are hard to reconcile. Well, who doesn’t hold views that are difficult to reconcile? So, over half believe HIV is a problem in Nairobi, but over 85% believe that their chance of being infected is 50% or less. They think HIV is a problem but they don’t think it’s a problem for them.

More worryingly, slightly under 40% believe that condoms prevent HIV. Thankfully, three quarters believe that condoms prevent pregnancy. But over 45% of respondents say that condoms often break. This suggests a need for more education on how to use condoms safely and perhaps even some work on ascertaining the quality of condoms that are available to people. Many of the condoms available to young people are donated by wealthy Western countries.

But despite so many thinking that condoms break or don’t prevent HIV or pregnancy, at least some of the same people still use them. The fact is, there isn’t much else available to prevent HIV. Of course, if people abstain from sex they are not at high risk of contracting HIV. That’s as long as they always get to choose whether or not to have sex, a questionable assumption. But most people will have sex eventually and waiting till you are married as a strategy has been well discredited over the years.

People living in a high HIV prevalence country like Kenya who think that they are not at risk of contracting HIV should consider the risk of those around them. They have sex with those around them, therefore they themselves are at risk. And if they don’t worry about HIV, they need to be reminded about other STIs, such as herpes, gonorrhoea, syphilis, chlamydia, genital warts and any others. Some STIs are far more common in Kenya than HIV. Some are also incurable and many put one at increased risk of contracting HIV.

People should also consider the risk of early pregnancy. Girls who get pregnant when they are still at school are, typically, excluded from school until they have given birth. They are said to be a bad example to the other students including, presumably, the one who made her pregnant. Once excluded from school, many girls never return. Early pregnancy has many social consequences and the value of the condom for reducing HIV and other STIs should not overshadow the value of the condom as a contraceptive.

It’s time for the Catholic and other Christian churches to see that children (as well as adults) are at risk of HIV, other STIs and early and unwanted pregnancies. They need all the help they can get and they certainly don’t need contradictory messages about the fact that they face many risks. They also need to be clear about the steps they can take to reduce their risk. If they are completely free to choose their sexual experiences and how those experiences take place, they are lucky. But even if they are not lucky, they can still take care.

To preach against the use of condoms is to expose people to unwanted pregnancy, deadly disease, suffering and numerous direct and indirect social consequences. To state one’s doctrine is fine, but don’t use lies to back it up and to scare people into doing what suits that doctrine.

Sex, Christians and Abstinence

Christians are unique in the animal kingdom in that they only experience the desire and even gain the ability to have sex once they are in a relationship of a sort that is approved by their church. If you don't believe me, just read a copy of a Christian bible. Ok, you have to interpret it a bit, but you'll find it there if you want to, and many people want to.

Or perhaps you would not take advice about sex from people who claim to only indulge in sexual intercourse for purposes of procreation? They are the last people I would ask for such advice. It is not supposed to be enjoyable and it is not even supposed to occur at all until approved by the church through marriage vows. Oh, and if you do 'transgress' you must feel terribly guilty and confess to someone who is probably exactly the same as you.

It's been a long time since (my last confession?) I have blogged as I have been travelling a relatively short distance very slowly. That's public transport in East Africa. And since I have reached my destination, Kigoma, Western Tanzania, there has been no electricity. The internet cafe I am writing from is supplied by a diesel generator that shudders and threatens to cut out at regular intervals. So I'll have to keep this posting short.

Several papers I have read on HIV transmission mention lack of diversion or entertainment and boredom as one of the factors in transmission. The man I am staying with mentioned the boring evenings several times and we killed some time by working late, by candle light, taking a long walk, stopping in a pub for a soda and chatting. But we would both have preferred to do something more entertaining or even just read with real electric lights.

Reading is not a big thing in Tanzania. It's very hard to get books and many people have difficulty with reading large amounts of text. So I don't even expect a big demand for books to develop any time soon. TV is popular but those who can afford TV may not be able to afford a generator to run it. Radio is a possibility, but evening with so few things to do and so little money to spend inevitably leads people to pursue cheaper and more readily available activities.

But there doesn't need to be a power cut or lack of things to do for sex to be an option, it's not just a way of filling in time. People don't need to list sex as a hobby no more than they need to list eating. They won't die if they don't have sex but nor will sexual desire go away. In fact, the desire for sex will not go away even if a load of Christians shout very often and very loudly about how you will die if you have sex of a sort they don't approve of.

One of the most extraordinary consequences of the HIV pandemic is the reaction of the Christian churches. They have been preaching abstinence, restraint, poverty and whatever else while practicing the opposite for two thousand years. They manage to attract the poorest people to give away a large chunk of their pittance to a church that lives in splendour. And they are supposed to abstain from their natural desires because of the dogma of people who, very often, know little about abstinence.

Even ostensibly secular states, such as the US, have spent millions of dollars at home and in developing countries on 'abstinence only' sex education. The word 'abstinence' is not just the absence of sex, a run of bad luck, perhaps. It refers to a decision to not have sex until marriage. The word has inherent religious and moral connotations. The policy has been a failure in the sense that most pledgers have sex as much as non-pledgers. In fact, many pledgers soon deny that they took a pledge. Worse still, the pledgers are less likely to use condoms or any form of birth control.

Here in East Africa, I have come across many interpretations of 'sex education', 'abstinence', moral issues, etc. There are those who teach 'abstinence' without even telling people what sex is. Of course, they know, vaguely, what sex is. But they are supposed to be teaching sex education. The word 'abstinence' is not clearly understood by people but even if plain English was used (without the religious and moral baggage), it seems difficult to comprehend the imperative to avoid doing something when you don't know what that something is.

Sex education programmes need to be mindful of what sex is, especially for those who claim not to indulge in sex. HIV is spread, to a large extent, by sex between heterosexuals. But people can be taught what sex is, what sexually transmitted infections are, how to ensure that you don't take risks that might result in unwanted pregnancy or sexually transmitted infection, etc. And the conditions of people's lives, the conditions that determine when, where and how sexual intercourse takes place, these have little to do with sex.

So if people are too squeamish or moral or religious or whatever to talk about sex, and I really think they should avoid the subject, they could better spend their time and money on infrastructure, poverty, gender inequality, poor health and education and many other areas of people's lives. It could be claimed, by the way, that many orphanages, schools and hospitals are run by religious institutions. But the money they spend represents a fraction of the money extracted from church followers. In areas like Kigoma, perhaps some of the churches could consider 'tax exemptions' or monetary rebates from the very poor.