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.

Justine Sacco: Dangerous Truths and Dangerous Falsehoods about HIV

[Reposted from the Don't Get Stuck With HIV website.]

An American on her way to South Africa is said to have Tweeted "Going to Africa. Hope I don't get AIDS. Just kidding. I'm white!" This is a heartless and insensitive remark to make. But what makes it most heartless and insensitive for a white American to say it is the fact that it is so true. In the US, African Americans accounted for 44% of all new HIV infections in 2010, despite representing only 12-14% of the population. Also in the US, men who have sex with men are said to represent about 4% of the population, but account for 63% of all new HIV infections in 2010, and a disproportionate number of them are black/African American.

Even in South Africa HIV prevalence among white people is very low. But national prevalence is amongst the highest in the world and there are more HIV positive people in South Africa than in any other country. While America has the worst HIV epidemic in the developed world, with over 1.1 million HIV positive people, the majority of infections arise among men who have sex with men and (to a lesser extent) intravenous drug users. HIV infection among white heterosexuals who have no serious risks, such as receptive anal sex or intravenous drug use, is very low.

The American who tweeted the first stupid, but sadly true, remark offended so many people that she arrived in South Africa to find that a storm had erupted on Twitter and she had lost her job. So, to make matters worse, she made a statement to a South African newspaper which contained a dangerous but often heard falsehood:

"For being insensitive to this crisis -- which does not discriminate by race, gender or sexual orientation, but which terrifies us all uniformly -- and to the millions of people living with the virus, I am ashamed."

This is completely untrue, as the figures for the US show so clearly. About two thirds of people living with HIV globally are black Africans. An estimated 60% of HIV positive people in Africa are female, compared to only 20% of new infections in the US in 2010. Hispanics and Latinos in the US made up 21% of new infections in 2010; the rate of infection was 2.9 times higher in Latinos than it was in white males; it was also 4.2 times higher in Latinas than in white women.

HIV most definitely does discriminate by race, gender and sexual orientation. This is not a new discovery, either. It may be an acceptable thing to say in certain circles, but we should never forget the differences between HIV in Africa, where the majority of HIV positive people live, and HIV in developed countries, where HIV is less prevalent overall, and is rare among heterosexuals who have no serious risk behaviors.

Justine Sacco, who tweeted the remark, is so right to think that she is very unlikely to be infected with HIV; a lot less likely than a black African, and also less likely than a black or Latino/Latina American. It is disturbing to think that so many people continue to believe or say otherwise. Why is HIV prevalence so high among black Africans and black/African Americans, yet comparatively low among white people, especially white men who engage in no serious risk behaviors?

What do Media Censorship and Manipulation, Gates, the BBC and Circumcision Have in Common?

Internews describes itself as an "international non-profit organization whose mission is to empower local media worldwide to give people the news and information they need, the ability to connect and the means to make their voices heard". But one of their much trumpeted programs claims to train journalists about the 'science' behind mass male circumcision programs in Kenya and creating demand for the procedure. There's quite a difference between training journalists on the 'science' of circumcision and creating demand, and the latter generally has little to do with empowerment.

The fact that the BBC's Media Action portal, Creating Demand for Voluntary Male Medical Circumcision, which is backed by the Bill and Melinda Gates Foundation, has named the work of Internews as an example of best practice also says a lot more about the three institutions' shared biases than about empowerment. Even the URL bluntly states the bias.

A press release gushes: "Internews’ training approach illustrates the benefits of training journalists to report accurately and impartially on culturally sensitive topics, such as VMMC. The training resulted in some 100 news stories focused on this high impact HIV prevention procedure that were published or broadcast. What was notable was that the media did not carry any negative news stories about the topic during the period that Kenya was rolling out the medical procedure in Nyanza Province." Oddly, another version of this press release uses the term "falsely negative news stories"; I wonder which is correct? Or is any negative news story 'falsely negative'?

So where is the impartiality in creating demand for mass male circumcision? If people have reservations about circumcision perhaps they have good reasons to. But if the procedure is as wonderful as proponents claim it is, why should such aggressive demand creation be necessary? It is claimed that Internews training "does not prescribe to journalists what to cover" but that their main concern is accuracy. Yet their country director Ida Jooste, perhaps inadvertently, flatly contradicts this claim.

She says that a "critical article was published in Uganda about VMMC quoting a poor-quality study which attacked the credibility" of the often cited Randomised Controlled Trials that took place in Kenya, Uganda and South Africa. Without citing that 'poor-quality' study, she goes on: "Rather than wait for the Kenyan media to pick up and run the story, Internews proactively convened a round-table with journalists and VMMC experts from the National AIDS and STI Control Program, and other organizations to analyze the story and examine its scientific arguments. As a result, not a single media outlet in Kenya chose to pick up or run the sensational story."

I don't think I'd use the word 'impartial' there. Ensuring that only positive coverage is aired and that negative coverage is quashed is media censorship and control, pure and simple. This is all paid for by the US taxpayer, though it seems the UK may now have something to do with it too.

Internews also 'worked with' (should that be 'worked on'?) civil society and health agencies working in the field of mass male circumcision. When they ran a conference focusing on women's 'involvement' in mass male circumcision, "to their delight" this resulted in 25 news and feature stories. This is pure manipulation, but those involved seem to express no shame, apology or even justification for it. Joost is even cited as saying "We believe that the impact of positive media coverage, or at the very least, the absence of negative coverage, complements and reinforces traditional public campaigns aimed at creating demand and behaviour change".

The above illustrates a concerted effort by a donor (Gates), an international media outlet (the BBC, via its corporate social responsibility wing) and a well-funded US non-profit, to control the Kenyan media. These parties then openly report their successful manipulation and censorship of the media, which has resulted in completely biased coverage of a public health program that is opposed by many of those who have taken the time to inform themselves about it.

What kind of foreign donor funded public health program, only carried out on certain African populations, is so important that it is necessary to manipulate the press so that they only report positive stories and that they don't report negative stories about it? If Kenyan people had any objections to this kind of neo-imperialism, would their press even report it? If the US wanted to impose a mass male circumcision program in the UK, would the BBC also collude with Gates, PEPFAR, CDC, UNAIDS and other parties to make sure objections were not heard? This must be what is meant by 'informed consent'.

The Media in Africa: Beware of Natives

BuzzFeed has photos of 10 signs photographed in South Africa during the apartheid era and it is truly shocking to think that, as the article points out, these signs only became illegal in 1994. But that's why it should be even more shocking that instances of extreme racism and apartheid style thinking should still be so common in the international media today. I have listed a number of examples below, with links to some of the most offensive articles I've read in the past few years.

These are just the tip of the iceberg and a full study would take years. But, in no particular order, let's start with the stories about condom 'recycling' in Kenya and condom 'rental' in Tanzania. Whether the journalists who wrote these stories were bored or desperate is just one question; but what about the media outlet that published them and the public who read them?

One that goes back a few years is the 'story' about starving HIV positive people on antiretroviral drugs eating cow dung in Swaziland. Numerous media outlets echoed that one and it cropped up several times. There was even a story about a woman in Namibia who  claimed to have eaten cow dung but then admitted that she had made it up. She didn't attract anywhere near as much publicity, though.

The ever-popular notion of 'African' sexuality is a trusty tool in the journalist's store of prejudices. Although it has been debunked many times, the media picture of Africans has remained faithful to their apartheid agenda. Africans are truly 'other', that's why there are such massive HIV epidemics in some African countries, isn't it?

The UNAIDS Modes of Transmission analysis, which produces the 'science' behind the media's HIV related racism has also been criticized, but why attack the source of so many stories that everyone seems to enjoy and find so completely inoffensive? UNAIDS even recognizes the true HIV danger in African countries, unsafe healthcare. But they keep that to themselves, publishing advice about avoiding non-UN approved health facilities in a booklet for UN employees, courtesy of the sweetly named 'UN Cares' (about its own employees).

Occasionally a journalist may allude to the use of African participants as research fodder, but people are too used to hearing about the oversexed and feckless African to care very much about such abuse, especially when it can always be dressed up as 'helping'.

It's coming up to about six years since the international media 'discovered' the Tanzanian albino attacks and killings, even though they had been reported in local media for some time. The sloppy and offensive coverage that followed this great 'scoop' for the BBC continues, as do the attacks on persons with albinism. Why revise a story that has won praise and awards? Of what importance are accuracy and insight when opportunities for self-adulation are at stake?

The disgusting US Christian right story of the use of adult pampers as a result of anal sex among men who have sex with men has even done the rounds in some of the local media. We see articles about African countries claiming that homosexuality is 'brought in' by foreigners. But where did the homophobia come from?

There are sometimes instances of the kind of media friendly racism that is 'roundly' condemned, trivial matters that keep readers entertained, much easier to write about than anything that matters. But what the media writes is clearly not yet a source of offence to most people. Perhaps in years to come sites will be able to list some of the shockingly abusive things the mainstream media published about African people, who knows?

Call for Inquiry into Media's Coverage of 'Tanzanian Albino Murders'

[Cross-posted from Blogtivist]

Instead of merely using the word 'witchcraft' in one of the earliest mainstream media articles on a series of murders of albino people in Tanzania, the author could as well have issued an edict that henceforth, all articles on the subject use a term with 'witch' in it, or some other, equally obscure term. Because every single subsequent mainstream media article on the subject did use such a term.

Other terms that crept in include: witchdoctor, foreign witchdoctor, herbal medicine, herbalist, ancient tradition, black arts, black magic, satanism (satanic inspired), traditional healer, magic potion, ritual medicine, ritual killing/murder, muti, muti medicine, sorcery, cannibals, magic potion, child sacrifice, superstition, taboo, fetish, voodoo, devil worship, occult, etc [There's a partial list of articles consulted on this page.]

'Here be Dragons...', began the BBC, and the rest of the 'free' press joined in unison. In the years following 2007, which marked the beginning of the media frenzy concerning attacks on and murders of albino people in Tanzania, no convincing explanation was ever given for why people should be attacked and killed just because, apparently, they are albinos.

Indeed, no light was shed on how that first article found online (there are likely to be many articles that have not been found by this study) had already 'established' that the 'four deaths (of albino people) in the past three months' (later reports suggest as many as 20 deaths in 2007) were a result of the work of 'witch-doctors'; but there was already a call for arrests.

Not that any subsequent research has shown that witches/witchdoctors/traditional healers, etc, were not behind the attacks and murders. In fact, one of the biggest single barriers to understanding these attacks and murders is that none of the articles examined have bothered to make clear exactly what they mean by 'witch', or whatever other term they used. For years, old people suspected of 'witchcraft' have been persecuted and lynched; such lynchings still occur, but they are surely not the target of these articles?

The World Health Organization estimates that in "some Asian and African countries, 80% of the population depend on traditional medicine for primary health care". Not only are conditions in most public health facilities in Tanzania appalling and dangerous, but many people are not able to afford them, neither the fees (official or otherwise), nor any of the other costs involved, such as transport and drugs. There is little left for poorer people other than some kind of local healer. Are these the targets of all the media articles about attacks on and murders of albino people in Tanzania?

Difficult as it is to believe, the government soon declared a 'ban' on all kinds of 'witchcraft'. The undefined set of activities that this poorly defined 'group' engage in becomes a target of intense media interest. But not for the first time. Poor and vulnerable old women and men in rural areas, who are probably becoming isolated from their communities, are not the only targets of savage persecution, beatings and lynchings. Virtually anyone said to be involved in any area of 'witchcraft', whether they hand out traditional cures for illnesses or potions said to make their clients wealthy, has gone through all manner of threats to their livelihood over the years.

In the mid 1990s, the Kenyan government was somehow persuaded that various elements of another poorly defined set of activities, devil worship, were 'rife' in rural areas, in schools, in (recently established) churches, in public places, everywhere. A government commission, headed by senior representatives of better established churches, was set up to investigate and several years later they, apparently, presented a report to parliament. The report was never made public, but the media was able to salivate over its possible contents for years, and the issue of devil worship is alive in the minds of many people who lived through those years.

What has witchcraft got to do with devil worship? Well, they were all lumped together by the Kenyan commission, just like all the terms listed above. "President Moi appointed the Commission in 1994 in response to public concern about a perceived resurgence of witchcraft, ritual murders, and other ostensibly "Satanic" practices associated with aspects of traditional indigenous religions." That one sentence damns a whole host of groups.

The document continues: "The Commission's report included numerous reports of ritual murder, human sacrifice, cannibalism, and feats of magic allegedly done by using powers acquired through such acts." Attacks on and murders of albino people in Tanzaina, from very early on, were seen as 'ritual' murders. Even descriptions of those murders became more lurid, listing the various parts of bodies, including their skin, and what they would be used for, bleeding and drinking of blood, hacking limbs off live victims, etc. Who wouldn't immediately see 'witchcraft' in these bloody attacks and murders in Tanzania?

Given the sheer weight of media footballs to choose from, few may remember Tanzania's (human) 'skin trade'. But it was a big enough story to attract attention for several years in the late 90s and early 2000s.  An article in 1999 refers to "a series of [at least three] brutal murders in which the skins and organs of the victims are apparently being sold for use in witchcraft". The article even claims that a "human skin can fetch a price of up to $9,000", just as the media later reveled in claims about how much money could be made from the parts and entire bodies of albino people.

Two years later it is reported that a gang, a ringleader called Adamu and twelve members, had been arrested in connection with similar murders, these also taking place in the Southern region of Mbeya (the majority of attacks on and murders of albino people took place in Mwanza, in the North West). The price range is now said to be "$2400 and $9600, apparently depending on the age of the victim". It is stressed that the ultimate market for these skins is West Africa and those involved are described as having become 'expert' at mutilating the bodies.

After another two years the issue is back on the BBC site; again it is stressed that the market is "outside Tanzania", and there is a "huge demand". Again, the murders are said to have taken place in the South of the country and there is mention of 'ritual' and 'witchcraft'. The total number of deaths is said to have been six. In common with the later attacks on and murders of albino people, it is implied that the skin is used by practitioners of witchcraft to bring wealth to the client: "This is also to educate people that they do not have to to use human skin to become rich".

None of the above tells us why albino people in Tanzania were subsequently mutilated and murdered, why the bodies of albino people were dug up and parts hacked off, why several people attempted to 'sell' an albino person for use by 'witchdoctors'. But it gives some idea of what the use of the term 'witch' and various other terms adds to an article about these horrific events: absolutely nothing. It simply labels the issue as a media football, to be kicked around along with other, similarly labelled bumf, a hotch-potch of rubbish that goes together to make up what counts as 'African' reportage.

It is estimated that over 100 albino people in Tanzania were attacked and over 70 killed since (probably) some time in 2006. Those who carried out the attacks, for whatever motive, deserve to be punished for what they did. But, despite hundreds of arrests claimed, hardly anyone has been punished. Reports are vague and unreliable, perhaps three or four people were convicted. One of those convicted was Kenyan, for human trafficking, as the victim was neither mutilated nor murdered.

So what's the problem? Witchdoctors are not that hard to find. If their work becomes a big secret they don't get many clients. The media loves to refer to how secretive they are, but given the sort of things that they have been implicated in over the years by the same media, who could blame them? Some may have become so secretive that they no longer get any clients at all; they may have found something safer to do. Just about anything would be safer, really.

More importantly 'witchdoctors' do not, according to evidence available, tend to charge a lot for their work; how could they, most of their clients are poor? So if 'witchdoctors' are not that hard to find, rich witchdoctors must really stand out. If there is any truth in the various rumors about how much they charge for 'potions' containing parts of mutilated and murdered albinos, some of them, probably a mere handful, must be noticeably well off. But no article found has produced evidence of a wealthy 'witchdoctor', only rumors, the media's stock in trade when writing about 'Africa'.

No article has produced evidence of a wealthy client, either. Artisanal miners and fishermen, mining and fishing being among the few sources of income in Mwanza, are frequently mentioned. But they, along with the hapless 'witchdoctors', have been blamed for many other things. Some sources mentioned politicians as possible clients of witchdoctors and predicted many further maimings and killings of albino people in the run up to the 2010 elections. Either there was no surge in violence against albino people, or the media merely failed to report it. So do politicians give large sums of money to 'witchdoctors' in return for success? Perhaps they now settle for potions that don't contain human remains.

Where is all the money involved in the often referred to 'lucrative' trade in albino body parts? Most articles stress the rural character of places where maimings and murders of albino people take place; they stress the poverty of the victims and the people around them; they stress the high levels of superstition and sometimes the low levels of education and the lack of opportunity in the area. How many rogue 'witchdoctors' were there, ever? And how many wealthy clients? Can the media, after all their 'investigations', over a period of so many years, tell us anything that is certain?

Or should we suspect that much of the talk of a 'lucrative' trade in albino body parts, talk that may have have contributed to so many maimings and deaths, was to a large extent the result of a media frenzy, that there are few wealthy 'witchdoctors' or clients, if any, that most, if not all of the perpetrators of these horrendous acts are still free, and that if anything could have been done to prevent such attacks it has not yet been done?

There were several further attacks and deaths this year. Late though it is, there needs to be a full inquiry into this phenomenon, one that takes into account the possible role of the media, the police and other officials, political, church and traditional leaders, everyone who may have something to add to finding out what went on, and what is still going on. We owe this, at least, to all the people who have already suffered and to those who may be protected by the results of a thorough investigation.

[I will be putting together data and sending it to the media outlets involved, calling for an inquiry into the shoddy coverage of the many attacks on and murders of Tanzanian albino people over the past seven years, and the failure of all those involved to identify the perpetrators and to protect other albino people from subsequent attacks and murders.]

CrowdOutAids: Crowdsourcing or Crowd Pleasing?

When something becomes one of the latest media obsessions, it's hard to find anyone criticizing it. That is a problem with crowdsourcing itself: if millions of google hits say it's brilliant it's hard to find the few who say otherwise. But evaluating something like crowdsourcing requires the negative, as well as the positive experiences.

Twitter demonstrates some of the problems. The more you use it, the less valuable it may be to you. If you want to communicate with like-minded people and organizations, you follow them and, hopefully, they follow you. But by the time you follow several hundred the number of communications you receive is far higher than anything you can get through, unless you do nothing else. Others following several hundred are also less likely to be reading tweets, including yours.

So when UNAIDS announce, very loudly because they can afford to, that they are 'crowdsourcing' youth about their views on HIV/AIDS, you know lots of people will take part. Who knows what the result will be, but to UNAIDS, who cares? They get lots of publicity, because using a word like 'crowdsourcing' gets media attention. They can publish whatever they want, regardless of what young people actually say. They have been publishing whatever they want for fifteen years, regardless of the evidence.

So the publicity says "Young people to write new UNAIDS strategy on youth and HIV". I just wonder, if some whippersnapper happens to question the HIV industry orthodoxy about Africans, especially young African females being highly promiscuous, how UNAIDS will respond. Because some have been urging them to investigate this highly racist assumption for years, without any result. Will those taking part share the UNAIDS meme about African sexuality, or will they fight it?

So far, UNAIDS have created a Facebook page. Their CrowdOutAids website just links to this page and there doesn't appear to be a lot going on yet. No doubt there will continue to be rave press releases about the success of the exercise. Again, UNAIDS can afford lots of 'successes'. But will the flabby, overfinanced institution do the one thing it has failed to do for the fifteen years since its establishment, shed light on why HIV transmission is so high among certain groups of people whose sexual behavior is by no means extraordinary?

By the way, there is a good article on crowdsourcing that raises questions about its use just after the Haiti earthquake, questions that were not raised by the subsequent flood of mainstream media articles. It's quite a different use of crowdsourcing than the UNAIDS program, but very enlightening. However, the author of the article received a lot of abusive comments because he dared to question the use of the technique.

I can't see UNAIDS risking such negativity. I'm confident that whatever we do hear, it will all be good news, and the media will report it accordingly.

'Counterfeiting' is a Problem That Can Only Be Solved By Big Pharma

If a business produces something and sells it for a price that covers costs and also gives a decent profit, that's a good model. Others may make the same thing, so a business needs to make the best and work hard to make sure they are not undercut. But most people will pay for something good rather than something that isn't up to scratch, if they can afford it.

However, if a business produces something and sells it for a price that is a complete distortion of the above business model, it is worthwhile for someone else to produce the same thing and charge a lot less. They don't even have to cut costs, they can just accept a lower profit. And those who have no chance of affording the expensive product may well be able to afford the cheaper one.

This is an oversimplification, but it is roughly what the pharmaceutical industry does, charges an outrageous price for something because they can. In addition, the industry depends on a form of protectionism called 'intellectual property rights'. Arguably, this has its uses, even that it is vital, but it is still a form of protectionism.

Often, the research that pharmaceutical companies claim to spend so much on is done by publicly funded, or partially publically funded, institutions. But there is little or no return to the public. And the amount spent on PR and marketing far exceeds what is actually spent on research.

So when someone else makes the same product but demands less for it, the industry reacts by resorting to all sorts of tricks to make sure the competition is destroyed. Competition, when you don't have a high level of trade protection, is not appreciated by the pharmaceutical industry.

The word 'counterfeit', therefore, can mean all sorts of things. It can mean a generic version of a branded drug, a fake version of a branded drug, a substandard version of a branded drug and probably other things. But a generic version of a branded drug is not a counterfeit and claiming that it is one threatens to deny  lifesaving treatments to many people in developing countries.

If drug companies don't want generic versions of their drugs to be produced, they should produce affordable versions themselves. There is clearly a huge market for them and a very good profit to be made. Dropping the price to affordable levels would also make the production of substandard and fake drugs a lot less tempting, perhaps not even worth the effort.

But instead of encouraging the production of generic drugs, the EU and, of course, the entire pharmaceutical industry, want to make sure affordable versions of drugs are not produced. They are currently trying to rope India into signing a 'trade agreement' whereby it will no longer be possible for the country to produce cheap drugs. Yet another form of protectionism.

India is one of the main sources of affordable drugs for developing countries. Some drugs will cost many times, perhaps even tens or hundreds of times more, just because they are protected by the sort of regulation that big industry claims to detest.

There is no doubt that some drugs are fake, made of materials that have no effect or are harmless, and this is unacceptable. But as long as ridiculous profits are made from drug pricing models, people will always find ways of selling their versions, no matter how useless or dangerous. It's not as if copyrighted drugs are always effective, or that they are never dangerous, either.

The pharmaceutical industry, already protected and subsidised in so many ways, wants more public money to be used to 'regulate' drug supplies in developing countries. Multinationals refuse regulation for themselves, but they seem to love the idea of regulating any competition.

Big Pharma have effectively created counterfeiting and many other related problems themselves, it's how they keep their profits so inordnately high. So they should sort it out themselves. If people object to the danger to the health and lives of so many people, they should aim their objections at the industry, the problem, not the mere symptoms of the problem.

The Science and Development Network have a selection of articles on the subject of 'counterfeit' drugs and some of the many issues involved. But the article doesn't really point out that Big Pharma don't lose out from counterfeiting because most of those who buy cheap drugs will never be able to afford the expensive versions.

Promoting Female Condoms in Salons is Great But Don't Forget Non-Sexual Transmission!

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.

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.

Paid to Fail: the Politics of HIV Research

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

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

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

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

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

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

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

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

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

Researchers Have No Opinion On Nosocomial HIV Infections in Zimbabwe

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why is HIV Prevalence So Low in Cuba? (Hint: Health Services)

Last October Esther Murugi, Kenyan minister for special programs, called for greater acceptance of gay people in society. Her call was met with predictable righteous indignation from most politicians and church leaders. And her call stirred up a bit of debate, a small amount of which may have been constructive.

In the last few days, Murugi called for isolation of HIV positive people as a means of eradicating the disease. Does she mean Kenya should isolate all 1.5 million HIV positive people for up to ten years and longer? Isolate them where? There are not enough schools for all the country's children nor hospitals for the country's sick people.

I'm inclined to give Murugi the benefit of the doubt. After all, she is willing to stand up for one of the most reviled groups in East Africa, gay people. And I don't think she can be held responsible for believing rubbish about HIV, given that global HIV policy is governed by a bunch of racist, sexist quacks.

Ok, she thinks that Cuba has one of the best controlled HIV epidemics in the world because they isolated HIV positive people. What she is probably not aware of is that Cuba has the highest number of doctors per head of population in the world. HIV positive people were actually treated, counseled and supported in Cuba, long before they were in most other countries.

Cuba, like many other countries (the US only recently dropped its travel ban on HIV positive people), panicked a bit at first. But they had one thing that most Western countries have and most African countries do not: good health services. And they took action to make sure that HIV transmission was reduced, both sexual and non-sexual transmission.

Murugi may also be confused because at one time Cuba didn't have access to antiretroviral drugs. That was because of US trade sanctions, not because those cruel Cuban leaders didn't care about HIV positive people. In fact, Cuba is probably one of the few countries in the world that acted decisively, quickly and effectively to limit the damage that HIV caused in most other countries, rich and poor.

Indeed, Cuba still manages to keep HIV transmission low, which is more than can be said for several Western, Eastern European, Asian, African and other countries. Cuba is fortunate in enjoying relative autonomy from UNAIDS and other institutions that seem to exert such a negative influence on HIV prevention and treatment policies around the world.

The minister is seriously misinformed, but misinformation about HIV is not uncommon, rather, it's the norm. And if any Kenyans happen to agree with Murugi, the answer is no, it's not going to happen. The country hasn't even tested the majority of HIV positive people yet or got the majority of people who need antiretroviral drugs on treatment. The country's health services do not have the capacity to even account for all HIV positive people, let alone isolate them, in any sense of the word.

If the minister wishes to make herself useful, she could raise the issue of gays again and perhaps take other measures to reduce HIV related stigma, rather than increase it. For instance, she could point to the evidence from WHO that a significant percentage of HIV comes from unsterile injections (and probably from other unsafe medical procedures).

The extremely low levels of HIV transmission in Cuba, from before HIV was identified, through the earliest days of the pandemic, right up to the present, probably have a lot more to do with the quality of their health services than with the amount of sex Cubans have or the types sexual practices most commonly found there. Levels of transmission in every country probably relates to quality of and access to health services and certainly doesn't relate to sexual behavior. But only Cuba seems to have noticed that.

And if Minister Murugi wants more Kenyan people to be tested, more HIV positive people to receive treatment and more HIV negative people to be protected, she needs to ensure than health services are cleaned up first. The last thing Kenya needs is for everyone to rush to their collapsing health services in the state they are in right now. That's only likely to increase transmission.

After Decades of Torpor, Is WHO Waking Up to the Problem of Unsafe Injections?

Recently, I wrote about condom manufacturers' apparent lack of concern that their products seem to get such bad press where clinical trials of HIV related medicines are concerned. I also linked to an article about a group of Nigerians  taking their government and various other state and non-state institutions to court because they used condoms correctly and consistently but still became infected with HIV. Several non-Nigerian institutions are also involved, including Family Health International (FHI).

Granted, numerous institutions have conspired to blame HIV transmission in Africa almost entirely on sexual behavior, when this is clearly not the whole story. But plaintiffs argue that they were used to test the efficiency of a particular brand of condoms, which were substandard. Perhaps there is evidence that this particular brand of condoms was faulty, in which case, they should indeed be withdrawn.

But the plaintiffs appear to want all condoms to be withdrawn from the market. It would be very surprising of it turned out that all condoms were faulty, despite the claims of the Catholic and other churches that this is so. There is plenty of evidence that condoms are effective in preventing the transmission of HIV and various other sexually transmitted infections. Condoms remain the most effective protection against sexual transmission of HIV.

What condoms don't do is protect people from non-sexual HIV transmission. This may sound too obvious a point to make, but there have been constant claims that abstaining from sex, only having sex with one, faithful partner and using condoms, are the only strategies for avoiding HIV transmission. Worse still, some claim that abstinence from sex is the only way. None of these claims are true.

Abstaining, being faithful and even using condoms will only protect from sexual transmission of HIV. They will not protect from non-sexual transmission, such as through intravenous drug use, unsafe medical practices or unsafe cosmetic practices.

Rather than admitting that they are wrong, the HIV hierarchy also claim that non-sexual HIV transmission is very rare in African countries. Such transmission happens in other countries, poor Asian countries, rich Western countries, Eastern European countries and everywhere else. But, it is claimed, it is too rare in African countries to merit more than about 1% of prevention funding. Never mind that health services range from appalling to non-existent in most African countries.

The WHO is relatively unenlightened when it comes to admitting that HIV prevention strategies are in need of review, given their almost total lack of success over the past few decades. But they do accept that unsafe injections are extremely common. Syringes and other injecting equipment are unsafe because single use equipment are being reused, without adequate (or perhaps any) sterilization.

According to the WHO, "in Africa alone, 20 million medical injections contaminated with blood from patients with HIV are administered every year". How they can also estimate that this results in only 23,000 HIV infections (also, a million hepatitis C and 21 million hepatitis B infections) every year is a mystery, given the efficiency of HIV infection through reused injecting equipment. But it gives an indication of the scale of the problem.

Apparently there is a campaign in Tanzania to have all single use injection equipment phased out and replaced with 'auto-disable' equipment, which breaks after use and therefore can't be reused. The sooner the better.

However, Tanzania's problem is not just with single use injection equipment being reused. They also have too few medical facilities, too few trained healthcare staff, too little equipment and various other things. It remains to be seen if the introduction of auto-disable syringes will be accompanied by improvements in supplies and all the other lacks. After all, there must be some reason why the health and lives of so many people are being put at risk for want of cheap equipment.

The Nigerian case is somewhat different because it appears to claim that a particular brand of condoms do not adequately protect against HIV infection. But the WHO findings, which probably seriously underestimate the problem, make it quite clear that sex alone is not responsible for HIV transmission in countries with sub-standard health services. Therefore, HIV prevention strategies should be extended to include the prevention of non-sexually transmitted HIV, especially nosocomial infections, those occurring in hospitals as a result of medical treatment.

[If you are interested in the question of whether people will be prepared to combine strategies, such as male circumcision, mcirobicides and pre-exposure prophylaxis with continued condom use, see my other blog.]

Why is HIV Policy in Africa Written By Racists?

Kenya appears to have yet another 'campaign' to reduce HIV transmission. This one purports to target HIV positive people, whom, some 'senior government officials' claim, have been ignored so far. This is an odd claim, considering the largest part of the vast sums of money being spent on HIV for many hears now has gone into treatment for HIV positive people. HIV prevention has received a very small amount of money and much of that has been frittered away on 'behaviour change programmes' widely acknowledged to be useless in Western countries.

Of course, HIV positive people must be part of the equation when trying to reduce HIV transmission. But so must HIV negative people. Concentrating on one group and ignoring the other has been counterproductive. One of the reasons that big funders are questioning the continuation of ever increasing funding for HIV drugs is that this approach hasn't yet had much effect on HIV prevalence. As HIV drugs are rolled out, more and more people continue to become infected. If there was an end in sight, perhaps in the form of significant reductions in transmission in high prevalence countries, funders might be persuaded to hang in for a bit longer.

The article is, in fact, very misleading:

"We have focused so much on empowering HIV-negative people to avoid infection. We now need to focus on people who are already infected and empower them to prevent new infections, re-infection, and maintain their own and their partners' good health," said Dr Nicholas Muraguri, head of the National AIDS and Sexually Transmitted Infections Control Programme.

I haven't seen much evidence of empowerment of HIV negative people, though I've seen many references to it. Whether the focus of most of the money and attention for the last several years on drugs and treatment has also included any empowerment for HIV positive people is another matter. It probably hasn't because pharmaceutical companies don't make money out of 'empowerment', they make money out of drug sales.

I have searched high and low for the guidelines in question without finding a copy but the article goes on:

One of the main aims of the guidelines is to ensure that all HIV-positive Kenyans are aware of their status; government statistics show that 84 percent of HIV-positive people do not know they are infected.

I hope this figure is out of date because it is the same as it was back in the 2008 Aids Indicator Survey, the data for which was collected in 2007. Since then, articles have claimed that several million more Kenyans have been tested, one even claiming that about 1.5 million were tested in a six week period near the end of last year.

The more people tested the better, but will any effort ever be made to figure out how people became infected? The assumption is still, despite plenty of evidence to the contrary, that most transmission in Kenya and other high prevalence African countries is due to unsafe sex.

Despite finding medical facilities to be too dangerous for UN employees, UNAIDS claims that medical transmission of HIV in Kenya is around 0.6%. There are children who are HIV positive whose mothers are not and nearly half the married women who are HIV positive are married to men who are HIV negative. Are we supposed to believe that all these women are becoming sexually infected with HIV through some relatively small number of men, to whom they are not married? Well, if you pander to the stereotype of the oversexed African, you may be happy with this explanation. But if you're an economist, no matter how bigoted, you may wonder how a large number women can have anything to gain by having sex with a small number of men to whom they are not married.

Dr Muraguri goes on to say "We want to de-stigmatise the HIV test so that HIV testing becomes a 'kawaida' [usual] thing". What better way could there be to stigmatise HIV than to assume that it is mainly sexually transmitted? Even the possibility that some HIV is transmitted non-sexually is not considered in most of the literature, perhaps from unsafe medical procedures, perhaps from unsafe cosmetic procedures or some other likely candidates. In what way, I wonder, is Dr Muraguri suggesting that this de-stigmatises anything? I see the sexual behavioural paradigm as the very source of HIV related stigma.

The article continues:

"At one point, every adult with sexually transmitted HIV was the HIV-negative partner in a discordant relationship," Muraguri said. "Over 44 percent of married HIV infected partners have an HIV-negative partner - if they are aware of their status, they can take steps to protect their partners from infection.

Yes, over 44% of married HIV positive people have a HIV-negative partner, and haven't people like the doctor ever wondered why this is? And if they were infected by some route other than sexually, their partners could also be infected non-sexually. Isn't it strange that HIV transmission in concordant relationships is so slow? Doesn't it suggest that sexual transmission of HIV alone may not be enough to explain the very high prevalence of HIV in Kenya and other African countries?

People who are aware of their status can protect their partners or protect themselves, but only if they know what the risks are. People can not protect themselves from medical, cosmetic or other non-sexual transmission by wearing a condom or even by abstaining from sex, especially if they don’t even know about these risks.

Anyone worried about reduced funding for HIV, as many claim to be at the moment, should be wondering why the various campaigns that were mere variations on Abstain, Be faithful and use a Condom (ABC), or even worse, abstinence only, have been so unsuccessful. As well as being intuitively unappealing, perhaps they were just barking up the wrong tree. Africans don't have more sex or more unsafe sex than non-Africans, so why should HIV prevalence be higher in many African countries than in many non-African countries?

In case there is any doubt remaining that the campaign excludes all but sexually transmitted HIV:

Prevention with Positives includes encouraging partner disclosure, scaling up prevention of mother-to-child transmission, increased condom use, large-scale male circumcision, and ensuring adherence to antiretroviral (ARV) drugs, which have been shown to significantly reduce the risk of mother-to-child as well as sexual HIV transmission.

This is all good advice, especially for sexually transmitted HIV. But for non-sexually transmitted HIV it offers nothing. People must know how they are becoming infected in order to protect themselves. The racist view that Africans are all having unsafe sex at such high rates that non-sexual transmission is almost irrelevant will not help to cut HIV transmission. But this latest Kenyan programme is being funded by some arch racists, it appears. The American President's Emergency Plan for Aids Relief, the Elizabeth Glaser Paediatric AIDS Foundation, and the US Centres for Disease Control are mentioned but apparently there are others.

Yet another stigamatising attitude is expressed by Nelson Otuoma, chairperson of the Network Empowerment of People Living with AIDS in Kenya (NEPHAK). This seems surprising, but he claims that the 18,000 or so members of NEPHAK have a "have a common message - they must not be generous with the virus, giving it away; they want to be mean with it, keeping it to themselves." There may have been rare (but very media friendly) exceptions of people deliberately or carelessly transmitting HIV but most people don't want their friends, partners, family or anyone else to become infected. Do people seriously believe otherwise?

Even nurses and other healthcare workers have been denied the knowledge that many people in Kenya probably became infected with HIV through a non-sexual route. Many people will list non-sexual ways of transmitting the disease, but it is clear that the assumption is that HIV is usually transmitted sexually. There is no reason for healthcare workers to assume that people face other risks because, regardless of how much money has been spent on improving healthcare (and I've seen little evidence of much of that in Kenya), they are bombarded with courses, publicity and literature on sexual transmission.

If I get to see the guidelines I'll link to them here. But I am very disappointed to hear that, yet again, non-sexual transmission of HIV has been ignored and the old stigma has been given more fuel, as if it needed any more. I have spoken to many people (laypeople and professionals) in Kenya, Uganda and Tanzania and most of them are willing to admit that things in health facilities are slack and must be giving rise to a lot of risks, whether for HIV or any other blood-borne diseases.

In addition to being able to access treatment when they are HIV positive, HIV negative Kenyans and other Africans need to be able to ensure that they stay negative. This means being made aware of the risks they face, not just sexual risks but risks they face when receiving medical treatment, cosmetic treatment, traditional medicine and other practices and the like. If they are not made aware of these risks, no matter how embarrassing it is to those in UNAIDS, CDC and other institutions that steadfastly deny that such risks exist, people will continue to become infected.

Unsafe medical practices are known to be common in some African countries, which means that everyone who receives medical treatment is at risk of becoming infected with HIV and other diseases. Continuing to maintain that sexual behavior is responsible for most HIV transmission among Africans, while warning non-Africans about these risks, is not the way to reduce HIV transmission. The belief that Africans have a lot of unsafe sex, and that’s why HIV prevalence is high in some African countries, is a prejudice: it arises despite evidence to the contrary, not because of evidence for the belief. But these two claims are what HIV policy in Africa tends to be based on.