Some people like to depict vaginal microbicides as being in the control of women, unlike male condoms and other methods of reducing HIV transmission. Pre-exposure prophylaxis (PrEP, the use of antiretroviral drugs by HIV negative people to reduce probability of infection) can also be depicted this way.
However, it is interesting to hear what many people say about contraceptive pills. Most women in East Africa opt for injectible versions of hormonal contraceptives because they say their husband or partner will not allow them to take the pills if they know they are contraceptives.
But if concerned people are interested in female controlled HIV prophylaxis and contraceptives, perhaps they should take a look at female condoms, a simple enough technology that has been available for over 20 years. They are not 100% female controlled, but they are another arrow in the quiver.
Whatever the HIV industry's feelings about female condoms, they are rarely discussed. And while male condoms are often discussed, the issue of women not necessarily having much control over the use of male condoms constantly arises.
Perhaps it's time to take another look at female condoms. There is convincing evidence that they would make an excellent complement to current HIV prevention programs. Maybe those expressing an aversion just don't know enough about them. I have asked a number of people and the ones who express an aversion, all of them, have never used female condoms. (Similarly, those who said male condoms sometimes burst have either said it never happened to them or it happened once or twice).
Apparently there is a program in Zimbabwe which aims to promote the female condom through hairdressing salons. This is a great venue for promoting knowledge of HIV transmission because so many women go to them and because hairdressers themselves need to know a lot more about HIV transmission than they currently do.
For example, most people who have been lectured, sorry, advised about HIV transmission have been told about sexual transmission, mother to child transmission and possibly something about intravenous drug use. Less likely, they'll have heard about transmission through blood transfusions.
It is unlikely they will have heard much about other forms of medical transmission, such as through the reuse of poorly sterilized equipment, such as injecting equipment, IV lines, dental equipment, etc, although such knowledge could reduce this kind of infection.
It is also unlikely they will have heard about the possibility of HIV transmission through unsafe cosmetic practices, such as tattoos, ear piercing, shaving (where cuts and abraisions can occur), hair straightening (where the relaxants can cause burning) and other practices.
Apparently PSI (Population Services International) is running the program, which makes it unlikely they will mention much beyond sexual transmission of HIV, but there is hope. And it's good to hear that they are promoting female condoms, it's time someone did.
Showing posts with label discordance. Show all posts
Showing posts with label discordance. Show all posts
Thursday, April 7, 2011
Wednesday, March 30, 2011
Uganda's HIV Epidemic: Mystery or Myth?
I have always worried about the way Uganda is held up as an example to other African countries on account of its early experience with HIV. What happened in Uganda earlier on is not the same as what happened later.
Early on in the epidemic, everything possible was done to reduce HIV transmission, both sexual and non-sexual transmission, in all their forms. Later, non-sexual transmission became more and more excluded and a set of myths about the efficacy of the ABC (abstain, be faithful, use condoms) strategy replaced any semblance of a coherent strategy.
The epidemic in Uganda took off earlier than in most other countries. HIV incidence, the rate of new infections, then declined and several years later, prevalence (the percentage of HIV positive people between the ages of 15 and 49) also declined.
It is not clear exactly why the epidemic took off when it did, nor is it too clear why incidence then peaked and declined. Measures to control the epidemic are likely to have played some part, of course, but how big a part has long been a matter of debate. Prevalence would have declined because of high death rates.
Once global HIV policy was thrown off course by ABC, or even AB or just A, it never got back on course. The burgeoning HIV industry's obsession with sex still rages and non-sexual HIV transmission, for example, through unsafe healthcare or cosmetic practices, is rarely talked about, let alone researched or investigated.
This leaves Uganda in a vulnerable position. The country receives a lot of HIV money, most of which is spent on drugs and care for HIV positive people. And the little left over for preventing new infections is spent on interventions that obviously don't prevent new infections.
Prevalence declines that resulted from high death rates have been reversed by a high rate of new infections. Those on treatment are likely to stay alive for longer, adding to increases in prevalence. But many HIV positive people still die, usually from treatable illnesses.
Not only is Uganda far from eradicating HIV, there is still a very serious epidemic in the country. Prevalence is bumping along, lower than it was during the worst years, true, but it has hardly changed for the last 10 years.
Infection rates in young people is often seen as a proxy for incidence because it's hard to measure incidence directly. But if young people who are just becoming sexually active are infected in large numbers, the epidemic is still very much alive. And 1.5% of people between 15 and 19 are HIV positive, 2.6% among girls and 0.3% among boys.
Of course, many of these teenagers could have been infected by mother to child transmission. But it's unlikely that they all were, unless this type of transmission is a lot more common that has been realized.
We are told that the highest burden of HIV, though, is now among married couples between 30 and 40 years old. In fact, it has been realized for some time that the majority of transmissions in Uganda appear to be a result of sex that is not 'unsafe' by any of the HIV industry's definitions.
HIV is common among those who don't have sex very much, are not likely to have several sex partners, and most of whom only have sex with a long term partner. Many, also, are in discordant relationships, their partner is not infected (or they did not infect each other). And half of the infected partners are female, so there goes the 'all men are promiscuous' theory of HIV transmission.
And that's the problem. If HIV is not primarily transmitted through unsafe sex, interventions that target unsafe sex will have little effect on transmission rates.
Yet the conclusion of Uganda's Ministry of Health is that they should encourage male circumcision, increase use of female condoms and awareness about HIV/AIDS. This may or may not reduce sexual HIV transmission. But after so many years watching HIV transmission stagnate, so many people becoming infected and so many dying, perhaps they could think about changing tack.
HIV is difficult to transmit sexually, yet it seems to be transmitted very rapidly in Uganda. Young people who are just starting to have sex are being infected quickly, which suggests that we are way off when it comes to our knowledge of transmission probabilities. Or perhaps not all HIV is transmitted sexually? Either way, we need to find out why transmission rates are so high in Uganda. Otherwise it will not be the only country with stagnating HIV prevalence figures.
Early on in the epidemic, everything possible was done to reduce HIV transmission, both sexual and non-sexual transmission, in all their forms. Later, non-sexual transmission became more and more excluded and a set of myths about the efficacy of the ABC (abstain, be faithful, use condoms) strategy replaced any semblance of a coherent strategy.
The epidemic in Uganda took off earlier than in most other countries. HIV incidence, the rate of new infections, then declined and several years later, prevalence (the percentage of HIV positive people between the ages of 15 and 49) also declined.
It is not clear exactly why the epidemic took off when it did, nor is it too clear why incidence then peaked and declined. Measures to control the epidemic are likely to have played some part, of course, but how big a part has long been a matter of debate. Prevalence would have declined because of high death rates.
Once global HIV policy was thrown off course by ABC, or even AB or just A, it never got back on course. The burgeoning HIV industry's obsession with sex still rages and non-sexual HIV transmission, for example, through unsafe healthcare or cosmetic practices, is rarely talked about, let alone researched or investigated.
This leaves Uganda in a vulnerable position. The country receives a lot of HIV money, most of which is spent on drugs and care for HIV positive people. And the little left over for preventing new infections is spent on interventions that obviously don't prevent new infections.
Prevalence declines that resulted from high death rates have been reversed by a high rate of new infections. Those on treatment are likely to stay alive for longer, adding to increases in prevalence. But many HIV positive people still die, usually from treatable illnesses.
Not only is Uganda far from eradicating HIV, there is still a very serious epidemic in the country. Prevalence is bumping along, lower than it was during the worst years, true, but it has hardly changed for the last 10 years.
Infection rates in young people is often seen as a proxy for incidence because it's hard to measure incidence directly. But if young people who are just becoming sexually active are infected in large numbers, the epidemic is still very much alive. And 1.5% of people between 15 and 19 are HIV positive, 2.6% among girls and 0.3% among boys.
Of course, many of these teenagers could have been infected by mother to child transmission. But it's unlikely that they all were, unless this type of transmission is a lot more common that has been realized.
We are told that the highest burden of HIV, though, is now among married couples between 30 and 40 years old. In fact, it has been realized for some time that the majority of transmissions in Uganda appear to be a result of sex that is not 'unsafe' by any of the HIV industry's definitions.
HIV is common among those who don't have sex very much, are not likely to have several sex partners, and most of whom only have sex with a long term partner. Many, also, are in discordant relationships, their partner is not infected (or they did not infect each other). And half of the infected partners are female, so there goes the 'all men are promiscuous' theory of HIV transmission.
And that's the problem. If HIV is not primarily transmitted through unsafe sex, interventions that target unsafe sex will have little effect on transmission rates.
Yet the conclusion of Uganda's Ministry of Health is that they should encourage male circumcision, increase use of female condoms and awareness about HIV/AIDS. This may or may not reduce sexual HIV transmission. But after so many years watching HIV transmission stagnate, so many people becoming infected and so many dying, perhaps they could think about changing tack.
HIV is difficult to transmit sexually, yet it seems to be transmitted very rapidly in Uganda. Young people who are just starting to have sex are being infected quickly, which suggests that we are way off when it comes to our knowledge of transmission probabilities. Or perhaps not all HIV is transmitted sexually? Either way, we need to find out why transmission rates are so high in Uganda. Otherwise it will not be the only country with stagnating HIV prevalence figures.
Wednesday, December 8, 2010
Academics Diligently Toe the Party Line
In addition to the sexualization of HIV, which yesterday's blog post was about, there is also the rather childish reflex which amounts to 'all men are violent, all women are victims'. There may be some truth in the reflex, that's not my objection. But it isn't very helpful in the HIV prevention field to assume that the virus is mainly spread by men in high prevalence countries. It isn't now and it never was.
An article notes: "The expectation that men rather than women are the index cases has been widely promoted by evidence of low condom use by men, a greater burden of sexually transmitted infections, male dominance in sex-related negotiations, greater number of sexual partners (including polygamous marriages), more frequent alcohol misuse, and greater likelihood of transactional (when a client exchanges money or gifts for sex) or intergenerational sex."
Of course, if HIV is not solely, perhaps not even primarily driven by sex, the assumption that it is driven by men becomes equally untenable. But even if HIV is primarily driven by sex, there has never been any clear support for the assumed role of men in playing a greater role in spreading HIV, with women being, almost always, innocent victims.
This article on discordant relationships, relationships where only one partner in a couple is HIV positive, finds that the woman is just as likely as the man to be the 'index case', the one infected (or the first one in the relationship to be infected). That has been recognized in the past but this paper collects together a number of studies involving thousands of participants.
In Kenya and Uganda, modes of transmission studies have shown that some of the most at risk people are those in long term, monogamous, heterosexual relationships, such as married people. Despite this, the term 'most at risk' has been reserved for men who have sex with men, commercial sex workers and intravenous drug users.
In spite of identifying these last three groups as being at high risk of HIV infection, very little money or programming has been used to target them in prevention programs. And in spite of the fact that HIV is clearly spreading inside stable relationships, programming has generally concentrated on advising people to avoid sex outside of such relationships.
You could say that the HIV prevention strategy has been, and continues to be, to advise people who are probably not engaging in unsafe sex to avoid unsafe sex. And the strategy simply ignores those who are probably at high risk of becoming infected. They are not completely ignored, but these groups receive very little attention, funding or viable prevention programs. This strategy hasn't changed much, despite 20 years of research.
HIV prevention programming has concentrated on a lot of finger-wagging about sex and 'unsafe' sex, when it has long been clear that sex, unsafe or otherwise, is unlikely to be involved in a substantial proportion of HIV transmission in the highest prevalence countries. Little or nothing has been said about non-sexually transmitted HIV.
Findings about discordant couples never seem to have set off alarm bells, even though many people in such relationships have claimed to only have had sex with their partner or to have taken precautions against HIV, unplanned pregnancy and sexually transmitted infections. In some couples where both partners were infected, they were infected by different strains of HIV.
Such evidence that HIV may not always have been transmitted sexually was sometimes interpreted as evidence that women can be promiscuous too. And it was sometimes even presented, uninterpreted, as if there is a great mystery to HIV transmission that is not related to sexual behavior.
The possibility of non-sexual transmission playing a part is briefly considered before being summarily dismissed. Perhaps the authors, Oghenowede Eyawo, Damien de Walque, Nathan Ford, Gloria Gakii, Richard T Lester, and Edward J Mills, are more concerned what their peers might think if they were to challenge the view that all Africans are promiscuous, irresponsible, ignorant and many other things that form the mainstream view of HIV in Africa.
An article notes: "The expectation that men rather than women are the index cases has been widely promoted by evidence of low condom use by men, a greater burden of sexually transmitted infections, male dominance in sex-related negotiations, greater number of sexual partners (including polygamous marriages), more frequent alcohol misuse, and greater likelihood of transactional (when a client exchanges money or gifts for sex) or intergenerational sex."
Of course, if HIV is not solely, perhaps not even primarily driven by sex, the assumption that it is driven by men becomes equally untenable. But even if HIV is primarily driven by sex, there has never been any clear support for the assumed role of men in playing a greater role in spreading HIV, with women being, almost always, innocent victims.
This article on discordant relationships, relationships where only one partner in a couple is HIV positive, finds that the woman is just as likely as the man to be the 'index case', the one infected (or the first one in the relationship to be infected). That has been recognized in the past but this paper collects together a number of studies involving thousands of participants.
In Kenya and Uganda, modes of transmission studies have shown that some of the most at risk people are those in long term, monogamous, heterosexual relationships, such as married people. Despite this, the term 'most at risk' has been reserved for men who have sex with men, commercial sex workers and intravenous drug users.
In spite of identifying these last three groups as being at high risk of HIV infection, very little money or programming has been used to target them in prevention programs. And in spite of the fact that HIV is clearly spreading inside stable relationships, programming has generally concentrated on advising people to avoid sex outside of such relationships.
You could say that the HIV prevention strategy has been, and continues to be, to advise people who are probably not engaging in unsafe sex to avoid unsafe sex. And the strategy simply ignores those who are probably at high risk of becoming infected. They are not completely ignored, but these groups receive very little attention, funding or viable prevention programs. This strategy hasn't changed much, despite 20 years of research.
HIV prevention programming has concentrated on a lot of finger-wagging about sex and 'unsafe' sex, when it has long been clear that sex, unsafe or otherwise, is unlikely to be involved in a substantial proportion of HIV transmission in the highest prevalence countries. Little or nothing has been said about non-sexually transmitted HIV.
Findings about discordant couples never seem to have set off alarm bells, even though many people in such relationships have claimed to only have had sex with their partner or to have taken precautions against HIV, unplanned pregnancy and sexually transmitted infections. In some couples where both partners were infected, they were infected by different strains of HIV.
Such evidence that HIV may not always have been transmitted sexually was sometimes interpreted as evidence that women can be promiscuous too. And it was sometimes even presented, uninterpreted, as if there is a great mystery to HIV transmission that is not related to sexual behavior.
The possibility of non-sexual transmission playing a part is briefly considered before being summarily dismissed. Perhaps the authors, Oghenowede Eyawo, Damien de Walque, Nathan Ford, Gloria Gakii, Richard T Lester, and Edward J Mills, are more concerned what their peers might think if they were to challenge the view that all Africans are promiscuous, irresponsible, ignorant and many other things that form the mainstream view of HIV in Africa.
Friday, October 29, 2010
HIV Institutions Need to be Frank About How Discordance Occurs
Some time back, a Ugandan woman who found out she was HIV positive shot dead her husband, who was HIV negative. This incident introduces an article about the urgent need to focus on HIV discordance, where one partner is positive and the other is negative. Sadly, the article doesn't shed any light on how discordance could occur.
There has been some research into discordance but much of it has gone no further than estimating numbers. Discordance occurs in about half of the couples where at least one partner is infected. And even among non-discordant couples where both partners are infected, there are quite a number where partners did not infect each other. This data is not collected very much, but it should be. How could it occur?
For a start, someone needs to be HIV positive to infect someone else through sexual intercourse. This may sound obvious, but I wonder if the woman who murdered her HIV negative partner knew. In Kenya, half of all married HIV positive women have a partner who is HIV negative. Far more women than men are infected with HIV and in Western Kenya there are more than five HIV positive women for every HIV positive man.
If you go along with the oft repeated orthodoxy, that most (some say 90%) HIV infection is sexually transmitted, you may wonder why women are so much more likely to be infected than men when plenty of data shows that men are far more likely to engage in 'unsafe' sex than women. Or you may simply dismiss this by saying that women are more 'susceptible' to infection through sexual intercourse.
This doesn't really explain differences between genders, especially in Western Kenya, where a large number of women must be having sex with a small number of HIV positive men. After all, as I've just said, 'unsafe' sexual behavior is higher among men. But you could, along with the orthodoxy, dismiss that with some other, equally unconvincing, argument.
Currently, guided by the orthodox wisdom, people who find out that they are HIV positive and their partner is not tend to be told that they must have had unsafe sex with someone other than their partner. There isn't really any other possibility, given the orthodox view. They could object that they have only ever had sex with their partner but the assumption is still made that they are probably mistaken or lying. Very often, that's the end of the partnership. Some people remain with their HIV positive partner, many don't.
It would be so much easier to admit that the figures suggest that a lot of HIV infections are probably not caused by 'unsafe' sex. Most women are not promiscuous. Nor are most men, despite all the spoken and written attestations to the sexual behavior of Africans, especially African men. Some men and some women are promiscuous, but that's true in every country in the world.
The assumption that high HIV rates can be put down to sexual behavior at levels that are not possible for human beings is institutional racism, because it informs most HIV policy and programing. The assumption is only made of Africans. In non-African countries, it is not assumped that most HIV transmission is sexual. There is more scope for actually believing what people say about their own sex lives.
It is also institutional sexism. The attested behavior of women, which makes up data collected by HIV institutions, is not used to inform policy and programing. On the contrary, the data is assumed to be lies because it does not accord with the current orthodoxy.
Bizarrely, the article concludes without mentioning non-sexual HIV transmission, the one mode of HIV transmission that might explain prevalence patterns but is rarely discussed by UNAIDS or any other HIV institutions. These institutions are tasked with preventing HIV transmission, yet they choose to ignore the possibility that appalling health services in countries like Kenya, Uganda and Tanzania could result in accidental transmission of HIV.
Another article goes through a similar process of describing some of the problems of discordance and also fails to say how such discordance could occur.
It is difficult to explain discordance without mentioning non-sexual transmission. But it is also unethical, for two reasons. Firstly, everyone has a right to know how they were infected, or how they may have been infected. Secondly, everyone has a right to know how to protect themselves and others from infection, whether it's sexual or non-sexual infection.
Africans are being denied their right to know how they were or may have been infected with HIV and they are being denied the knowledge they need to protect themselves. And it's not just adults that are at risk, infants and children are also at risk. Parents need to be aware of risks that their children face in order to mitigate those risks.
Where infants and children are found to be HIV positive, it vital to establish the source of their infection. It needs to be clear that they were not necessarily infected by their mother, who may not even be infected or may be infected with a different strain of the virus. This phenomenon has often been documented but it has yet to be investigated in African countries.
HIV discordance is a lot easier to explain when it is frankly accepted that not all HIV infection is a result of sexual intercourse. The many non-promiscuous people, virgins, infants, children and no longer sexually active people who find they are HIV positive have a right to know this. And we all have a right to know how HIV is transmitted and how to protect ourselves, especially in high prevalence countries with failing health systems.
There has been some research into discordance but much of it has gone no further than estimating numbers. Discordance occurs in about half of the couples where at least one partner is infected. And even among non-discordant couples where both partners are infected, there are quite a number where partners did not infect each other. This data is not collected very much, but it should be. How could it occur?
For a start, someone needs to be HIV positive to infect someone else through sexual intercourse. This may sound obvious, but I wonder if the woman who murdered her HIV negative partner knew. In Kenya, half of all married HIV positive women have a partner who is HIV negative. Far more women than men are infected with HIV and in Western Kenya there are more than five HIV positive women for every HIV positive man.
If you go along with the oft repeated orthodoxy, that most (some say 90%) HIV infection is sexually transmitted, you may wonder why women are so much more likely to be infected than men when plenty of data shows that men are far more likely to engage in 'unsafe' sex than women. Or you may simply dismiss this by saying that women are more 'susceptible' to infection through sexual intercourse.
This doesn't really explain differences between genders, especially in Western Kenya, where a large number of women must be having sex with a small number of HIV positive men. After all, as I've just said, 'unsafe' sexual behavior is higher among men. But you could, along with the orthodoxy, dismiss that with some other, equally unconvincing, argument.
Currently, guided by the orthodox wisdom, people who find out that they are HIV positive and their partner is not tend to be told that they must have had unsafe sex with someone other than their partner. There isn't really any other possibility, given the orthodox view. They could object that they have only ever had sex with their partner but the assumption is still made that they are probably mistaken or lying. Very often, that's the end of the partnership. Some people remain with their HIV positive partner, many don't.
It would be so much easier to admit that the figures suggest that a lot of HIV infections are probably not caused by 'unsafe' sex. Most women are not promiscuous. Nor are most men, despite all the spoken and written attestations to the sexual behavior of Africans, especially African men. Some men and some women are promiscuous, but that's true in every country in the world.
The assumption that high HIV rates can be put down to sexual behavior at levels that are not possible for human beings is institutional racism, because it informs most HIV policy and programing. The assumption is only made of Africans. In non-African countries, it is not assumped that most HIV transmission is sexual. There is more scope for actually believing what people say about their own sex lives.
It is also institutional sexism. The attested behavior of women, which makes up data collected by HIV institutions, is not used to inform policy and programing. On the contrary, the data is assumed to be lies because it does not accord with the current orthodoxy.
Bizarrely, the article concludes without mentioning non-sexual HIV transmission, the one mode of HIV transmission that might explain prevalence patterns but is rarely discussed by UNAIDS or any other HIV institutions. These institutions are tasked with preventing HIV transmission, yet they choose to ignore the possibility that appalling health services in countries like Kenya, Uganda and Tanzania could result in accidental transmission of HIV.
Another article goes through a similar process of describing some of the problems of discordance and also fails to say how such discordance could occur.
It is difficult to explain discordance without mentioning non-sexual transmission. But it is also unethical, for two reasons. Firstly, everyone has a right to know how they were infected, or how they may have been infected. Secondly, everyone has a right to know how to protect themselves and others from infection, whether it's sexual or non-sexual infection.
Africans are being denied their right to know how they were or may have been infected with HIV and they are being denied the knowledge they need to protect themselves. And it's not just adults that are at risk, infants and children are also at risk. Parents need to be aware of risks that their children face in order to mitigate those risks.
Where infants and children are found to be HIV positive, it vital to establish the source of their infection. It needs to be clear that they were not necessarily infected by their mother, who may not even be infected or may be infected with a different strain of the virus. This phenomenon has often been documented but it has yet to be investigated in African countries.
HIV discordance is a lot easier to explain when it is frankly accepted that not all HIV infection is a result of sexual intercourse. The many non-promiscuous people, virgins, infants, children and no longer sexually active people who find they are HIV positive have a right to know this. And we all have a right to know how HIV is transmitted and how to protect ourselves, especially in high prevalence countries with failing health systems.
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