More junk science underestimating HIV from medical injections

[Cross posted from the Don't Get Stuck With HIV blog - for more about HIV infection through unsafe healthcare and cosmetic practices and how to protect yourself, visit the site.]

AIDS experts still haven’t figured out what is different about Africa that can explain why HIV epidemics there are so much worse than elsewhere. The continuing failure to find what is different about Africa’s epidemics exposes persistent (intentional or natural) incompetence on the part of respected researchers.

Specifically, scores of studies that have tested, followed, and retested hundreds of thousands of HIV-negative Africans to find when and how they get HIV have failed to trace the source of observed new infections.[1] Without tracing the source, there is no way to say infections came from sex – but “HIV from sex” is nevertheless the conclusion (and racist slur) from decades of incompetent, incomplete research. When such studies find people with new HIV infections who report no possible sexual exposure to HIV, researchers characteristically reject the evidence: “hmmmm, an African with HIV…must have lied about sexual behavior….”

With that “scientific” method, the US National Institutes of Health and UK’s Medical Research Council could save money by paying researchers sitting in offices in Baltimore, US, or Oxford, UK, to make up data to fit pre-determined conclusions. That would be more efficient than paying them to go to Africa, collect data, and then reject what doesn’t fit desired conclusions.

While funders have avoided funding good science to explain Africa’s HIV epidemics – for 30 years and counting – they have been all too happy to fund junk science that will get the desired results. One popular junk-science strategy to get desired results has been to model Africa’s HIV epidemic with unreliable parameters and weak, selected, or made-up data.

The latest paper by Pepin and colleagues[2] falls into that category of junk science – presenting a model with unreliable parameters and data, and using results from the model to claim that unsafe medical injections accounted for less than 1% of new HIV infections in Africa in 2010 (8,000-16,000 from injections vs. 1.9 million total new infections[3]).

Several obvious problems with the estimate are as follows:

1. Pepin’s assumed rate of HIV transmission through a contaminated syringe or needle – 1 in 150-300 injections – is far too low to allow observed HIV outbreaks through health care in Russia, Romania, Libya, and elsewhere. If those outbreaks occurred – they did! – then Pepin’s proposed rate of HIV transmission through injections is misleadingly low. For example, in Russia in 1988-89 hospital procedures passed from HIV from 1 child to more than 260 children in 15 months. Most transmissions in this outbreak came from children who had been infected less than 6 weeks earlier – enough time for infected children to get dozens but not 150-300 skin-piercing procedures followed by reuse of unsterilized instruments.[4]

2. Pepin’s same model estimates 4,300-8,500 new hepatitis C virus (HCV) infections in Africa from unsafe injections in 2010, less than 1% of estimated new HCV infections (cf: an estimated 18 million Africans were living with HCV in 2005[5], which corresponds to approximately 1 million new infections per year). Because virtually all new HCV infections come from blood, not sex, it’s likely that unsafe injections account for a lot more than 1% of new HCV infections – and by extension, more than 1% of new HIV infections as well. Furthermore, other skin-piercing procedures aside from injections likely account for a lot of new HCV infections – and by extension a lot of new HIV infections as well.

3. Pepin’s estimates distract from facts that need answers. Why do 16%-31% of HIV-positive children in Mozambique, Swaziland, and Uganda, have HIV-negative mothers (among children with tested mothers)?[6] Why do so many mutually monogamous couples find that one or both partners are HIV-positive?

In his conclusion, Pepin commendably recognizes “other modes of iatrogenic transmission” including[2]: “use of multi-dose medication vials, phlebotomies with re-used needles, dental care with improper sterilisation of instruments, unscreened transfusions, ritual scarifications and circumcisions performed by traditional practitioners… Better measurement of such exposures and of their impact on viral dynamics is an essential first step…”

Even so, Pepin does not hit the nail on the head. What is required to measure the “impact [of such procedures] on viral dynamics” is to trace HIV infections to their source. When infections are traced a hospital, dental clinic, tattooist, etc, then continue with outbreak investigations to determine the extent of the damage from unsafe health care or other skin-piercing procedure.

References

1. Gisselquist. Randomized controlled trials for HIV/AIDS prevention in Africa: Untraced infections, unasked questions, and unreported data. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 14 June 2014).

2. Pepin et al. Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010. PLOS one 2014; 9: 1-8. Available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0099677 (accessed 14 June 2014).

3. Annex table 9 in: UNAIDS. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access, progress report 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241502986_eng.pdf?ua=1 (accessed 15 June 2014).

4. See: http://dontgetstuck.org/russia-cases-and-investigations/

5. Hanafiah et al. Global epidemiology of hepatitis C virus infection. Hepatitis 2013. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hep.26141/pdf (accessed 14 June 2014).

6. See pages for Mozambique, Swaziland, and Uganda at: http://dontgetstuck.org/cases-unexpected-hiv-infections/; see also: http://dontgetstuck.wordpress.com/cases-unexpected-hiv-infections/).

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.

South African National HIV Survey Betrays Those Facing Non-Sexual Risks

The latest South African National HIV Prevalence, Incidence and Behaviour Survey, 2012 was released recently. Much of the media coverage concentrated on things like the worrying increase in HIV prevalence compared to the last survey, which was carried out in 2008, said to be the combined result of new infections and a big increase in the number of people living longer with HIV as a result of being on antiretroviral therapy.

The report is a useful document, as far as it goes. But there isn't even a hint that several non-sexual modes of HIV transmission could be contributing to the worst HIV epidemic in the world (in terms of number of people living with HIV, 6.4 million). This is a lot more worrying than the increase in prevalence, because failing to address non-sexual modes of transmission will result in people continuing to be infected through unsafe healthcare, unsafe cosmetic practices and unsafe traditional practices.

Underlining the clear assumption that almost all HIV transmission is a result of unsafe sexual behavior, there is a lot of attention paid to mass male circumcision programs. These are not going so well in South Africa because the majority of circumcised people chose this as a tribal rite, not because they had been hoodwinked into believing that it would save them from various diseases, HIV just being one of them. But the report fails to stress that this means most circumcised males in South Africa faced a far higher risk of being infected with a number of diseases by being circumcised in unsterile conditions.

The report also agonizes over the usual 'behavioral determinants of HIV', such as early sexual debut (a minority of males and females become sexually active at a young age, the vast majority don't), 'intergenerational' sex (a minority, about a fifth of females do, most males don't and this issue has been questioned recently), multiple sexual partners (also a minority do this, more males than females, although HIV prevalence is far higher among females) and condom use (increasing, but probably too low to have much impact on transmission).

However, simply ignoring the possible significance of how people respond to questions is the most arrogant, and probably the most dangerous aspect of the report. There is a list of reasons people gave for believing they would not contract HIV and a few from this list were cited in the media, triumphantly, because some people who thought they would not contract the virus were already infected. Here's the list, with the number of people giving the response and the percentage:

Reasons for belief one would not contract HIV - number and % of cases

I have never had sex before 21,150, 11.0
I abstain from sex 21,147, 21.3
I am faithful to my partner 21,144, 32.0
I trust my partner 21,149, 22.5
I use condoms 21,146, 19.2
I know my HIV status 21,136, 9.8
I know the status of my partner 21,134, 4.4
I do not have sex with sex workers/prostitutes 21,112, 1.7
My ancestors protect me 21,070, 1.1
God protects me 21,142, 2.5
I am not at risk for HIV 21,151, 8.9
Other 21,142, 10.4

Do those carrying out the survey never, for one moment, suspect that some people might be telling the truth? Some people who have never had sex before are being told for the first time that they are HIV positive, and that it's almost certain they were infected through some kind of unsafe sex. What efforts are made to find out how they were infected? What about those who are faithful to their partner? Is their partner tested?

The authors of the report seem to relish the term 'evidence-based' when referring to various different 'interventions' that are expected to reduce HIV transmission; when these interventions appear to fail, those who become infected, or who give inconvenient answers to survey questions, are blamed for their 'sexual behavior'. If the researchers don't even check how people become infected, in what way are the interventions evidence-based? If people are not believed when the answers don't suit the researchers, why should we accept other parts of the report where the answers are in line with what the researchers expect to hear?

Assuming that HIV is almost always transmitted through 'unsafe' sexual behavior, regardless of all the indications that it is also transmitted through unsafe healthcare, cosmetic or traditional practices, is a betrayal of HIV positive people; it is also a betrayal of those who still risk becoming infected through such routes. These non-sexual routes urgently need to be addressed by investigating and cleaning up health centers, salons and other potential locations, and by warning patients about the dangers of being exposed to the blood and bodily fluids of other people.

UNAIDS' 3 Ones: One Disease, One Theory, One Solution

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

According to Avert.com "more than $400 million [of donor funding] was committed to HIV and AIDS in 2007/2008". However, less than a quarter of that funding, probably around 20%, was spent on 'prevention', with the usual assumption that almost all HIV is transmitted through heterosexual behavior. Around 60% is estimated to have been spent on treatment and care, say around $240 million.

It's tremendous that a lot of money is being spent on treating and caring for people who have been infected with HIV. Not all HIV positive people are currently eligible for treatment. Perhaps UNAIDS' claim that 60% of those who are eligible were on treatment at some time, although the figure, however many hundreds of thousands it may be, does not discount those who have died or who have been otherwise lost to follow up.

Around 95% of Tanzanian people are HIV negative. Out of the 1,470,000 people who are living with HIV, between one and two thirds may be on treatment. That's 1-2% of Tanzanian people, at the most. So how do those who control the money decide how to spend the approximately $80 million in order to reduce transmission of HIV; what kind of prevention activities should be prioritized among those 46,300,000 Tanzanians who are still uninfected?

UNAIDS has a slogan (aside from their 'three ones' slogan alluded to in the title above) that goes 'know your epidemic - know your response'. This makes it sound like UNAIDS believes that there are different epidemics in each country, and perhaps even different subepidemics within each country. But their response is always to treat HIV epidemics in Africa as if they are all virtually the same, although they may vary in intensity: but they are all assumed to be 'driven' by heterosexual behavior.

It's not very clear how far $1.70 per head can go towards 'changing people's sexual behavior', but that hasn't stopped UNAIDS and other big players in the HIV industry (and some of them are very big players indeed) from trying. Billions have been spent on wagging fingers at rooms full of adults and children over the almost 20 years of UNAIDS' existence.

Luckily there are a few things that can be done to help establish that HIV is probably not entirely heterosexually transmitted and that most finger-wagging exercises are a complete waste of money (their inherent paternalism is probably not considered to be a disadvantage; perhaps neither is their clearly demonstrated ineffectiveness).

For example, in Tanzania (and most other countries) there are only a few places where HIV prevalence is really high. Here's a list of prevalence by region (the five with the lowest prevalence are the Zanzibar archipelago):

Njombe 14.8
Iringa 9.1
Mbeya 9
Shinyanga 7.4
Ruvuma 7
Dar es Salaam 6.9
Rukwa 6.2
Katavi 5.9
Pwani 5.9
Tabora 5.1
Kagera 4.8
Geita 4.7
Mara 4.5
Mwanza 4.2
Mtwara 4.1
Kilimanjaro 3.8
Morogoro 3.8
Simiyu 3.6
Kigoma 3.4
Singida 3.3
Arusha 3.2
Dodoma 2.9
Lindi 2.9
Tanga 2.4
Manyara 1.5
Mjini Magharibi 1.4
Kusini Unguja 0.5
Kusini Pemba 0.4
Kaskazini Pemba 0.3
Kaskazini Unguja 0.1

And there are further generalizations that can be made about HIV in Tanzania. Prevalence tends to be higher among females, urban dwellers, wealthier people, people with higher levels of education and employed people. It tends to be lower among men, rural dwellers, poorer people, people with lower levels of education and unemployed people.

UNAIDS tends to 'analyze' these features, which are shared by all high HIV prevalence countries, and conclude that wealthier, urban dwellers with jobs have bigger 'sexual networks' (etc) as if every person with HIV must have a 'sexual network' (etc). But there are other figures they could avail of when they are in an analytical frame of mind.

For example, while women are said to be more susceptible to HIV infection for various biological reasons, wealthier, urban dwelling, better edcated women with a job are also much more likely to attend ante natal clinics (ANC) and seek the assistance of some kind of trained health professional when they are giving birth.

Now, you might expect women who attend ANCs and have assisted deliveries to be less likely to be infected with HIV, but you'd be wrong. In many instances they are more likely to be infected, sometimes a lot more likely. Indeed, some countries with the highest HIV prevalence figures also have the highest ANC and attended birth figures, Swaziland, Lesotho, Namibia and Zimbabwe, for example. The contrary tends to be true of low prevalence countries in sub-Saharan Africa.

This is not to say that HIV is never transmitted through heterosexual sex, or that it is always transmitted through unsafe healthcare (even among women). It's just a clear indication that we need to know exactly what contribution heterosexual behavior makes to epidemics, and what contribution may be made by non-sexual routes, such as unsafe healthcare, cosmetic care and perhaps other practices.

The whole concept of a UN agency set up to 'fight' one disease is bad enough. But it's a whole lot worse if they and the rest of the industry continue to squander precious resources on poorly targeted and ineffective interventions. Resources need to be spent on health, defined as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (there's no irony intended in citing WHO here).

Apparently one third of all aid in Tanzania is being spent on HIV, which leaves the other two thirds to be spent on other development areas. So perhaps some of that will eventually be used to address the many poorer, less well educated, jobless people living in rural areas with virtually no infrastructure or social services, but who are HIV negative. They will likely remain negative if even a fraction of available donor funding is spent on working out the relative contribution of unsafe healthcare to the worst HIV epidemics in the world and addressing this issue, however belatedly.

HIV Strategy: Blaming the Victim and their Individual Behavior

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

Since the early days of HIV/AIDS, finger pointing has been the main publicity angle. In Western countries the collective finger was pointed at men who have sex with men. Their reaction was to object to the finger being pointed at them and to insist that everyone is equally at risk. Though some still believe that everyone is equally at risk, it is not true. In Western countries the majority of HIV transmissions have always been among men who have sex with men, with a smaller proportion of transmissions through intravenous drug use.

But things are quite different in developing countries, particularly high HIV prevalence African countries. In high HIV prevalence countries men who have sex with men, intravenous drug users and even sex workers contribute a relatively small proportion of HIV transmissions. In fact, the largest contribution still appears to come from those with little or no risk; mainly monogamous heterosexuals. So the process of finger pointing often turns into one of victim blaming. After all, you can't point the finger at everyone around you, nor at someone who is HIV negative; so the clearest 'evidence' of unsafe sexual behavior becomes HIV positive status.

This gives rise to the task of explaining how a virus that is difficult to transmit through heterosexual sex outside of Africa is so frequently transmitted through that route in Africa. The HIV industry needed to show that 'Africans' must be promiscuous, ignorant and unhygienic. This wasn't too difficult because population control advocates (the word 'eugenics' is no longer fashionable), a significant proportion of wealthy NGOs operating in Africa, had had been playing the over-sexed, under-educated slum-dweller cards for decades.

The processes of pointing the finger at a particular group whose behavior was disapproved of, blaming those infected with HIV for their status, and concluding that HIV is all a matter of individual behavior, threw off course any efforts to reduce HIV transmission in developing countries. Although 'prevention' activities only receive a small proportion of HIV funding, that is still a massive amount of money. But prevention activities have rarely gone beyond exhortations to 'behave' in a particular way. The finger-wagging programs perfected by population control NGOs decades before HIV was identified became, and often remain, the state of the art of HIV prevention.

There has been plenty of research showing that these finger-wagging programs are of little or no benefit (except to the NGOs). An example of such research shows that "peer education programs in developing countries are moderately effective at improving behavioral outcomes, but show no significant impact on biological outcomes". There is a voluminous body of literature showing that you can't simply wag your finger at people and expect them to change their behavior, whether the aim is to address substance abuse, dangerous driving, over-eating or anything else.

Sometimes the association of HIV transmission with individual behavior is further connected with conditions that are beyond the control of the victim, for example, poverty. But this has also given rise to confusion: there is plenty of evidence that HIV in African countries is transmitted among wealthier people. This challenges the idea that HIV epidemics are driven by sexual behavior because, even if wealthy people 'can afford to have a lot of sex and a lot of partners', as the HIV industry would have it, there would need to be some poor people involved in this theory. Rich people don't pay other rich people for sex.

Instead of looking beyond sex, or sex and poverty, it seems some researchers are convinced they will eventually find out how sex and economic inequalities 'drive' HIV epidemics. One paper concludes that "Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in [sub-Saharan Africa]". But they don't seem to consider the possibility that their protohypothesis about sex is simply wrong. They don't seem to think that non-sexual transmission may be a very significant factor in the spread of HIV among wealthier people.

HIV can be transmitted through unsafe healthcare and other skin-piercing processes, such as various cosmetic processes. Wealthy people tend to have better access to healthcare. In fact, urban dwellers also tend to have better access to healthcare. Perhaps this is why the above paper found that HIV is "generally concentrated among wealthier men and women". This may also explain why HIV "was concentrated among the poor in urban areas but among wealthier adults in rural areas" in a number of countries.

Instead of trying so hard (and failing, over and over again) to find out what it is about the sexual behavior of wealthy people and urban dwellers, perhaps researchers should look at non-sexual risks, as well as sexual risks. Could the risks that people face be determined by their wealth and environment, precisely because they are not sexual risks, but healthcare and other risks? These risks are clearly not *individual* risks. They relate to health-seeking behavior, but it is not the behavior of wealthy and/or urban-dwelling people that gives rise to infection with HIV in a hospital or salon; the risk of infection depends on whether the facility is safe or not (which might vary considerably over time).

Some historians of HIV, such as Jacques Pepin (The Origins of Aids), admit that HIV was mainly transmitted through unsafe healthcare for many decades, and hardly ever through sexual behavior. But they don't explain how healthcare transmission magically disappeared in the 1980s even though conditions in many African countries remain very unsafe (although how unsafe they are is still a dangerously under-researched field).

Coupled with the magical disappearance of the risk of HIV transmission in under-equipped, under-staffed and badly run health facilities is the magical re-appearance of the promiscuous, ignorant and dirty African, though for many, this had never really gone away. Pepin vaguely mentions things like 'urbanization' as the main explanation for levels of promiscuity for which there has never been any evidence and which do not explain very high rates of heterosexual transmission of HIV anyway.

Ugandans have recently responded to having the finger pointed at them by allowing an 'anti-homosexuality' bill to be passed, effectively saying 'it's not us, it's them'. Various human rights groups, and even some donors, may belatedly object to such disgusting measures, which are being copied by other African countries. But the objection needs to be directed at the approach to HIV that began a long time ago, and began in Western countries, not in African countries. Men who have sex with men are by no means the only group who have been blamed for HIV epidemics. Other groups include long distance drivers, sex workers, house girls, fishermen, miners, and many others. It's this finger-pointing approach that gives rise to the stigma that those pointing the finger claim to abhor.

Thirty years into the HIV epidemic (I'm adopting the view that HIV is not a pandemic because most people don't face any risk of being infected and prevalence is, and will remain, low in most countries) research institutions, NGOs, international bodies and, perhaps most importantly, donors are still obsessing about sexual behavior and pretending that HIV status is up to the individual when it is clear that a large, but as yet unestimated, proportion of infections is a result of unsafe healthcare and other skin-piercing processes.

UNAIDS' Dubious Claims about HIV/AIDS 2013

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

UNAIDS risk missing their target of reducing "sexual transmission of HIV by 50% by 2015". But there is a way of meeting that target, and they could meet it by tomorrow. If they belatedly admit that HIV is far more easily transmitted through unsafe healthcare, they could begin to estimate the contribution of things like reuse of needles, syringes and other equipment that comes into contact with blood and other bodily fluids.

This would also greatly assist their progress towards their 'ZeroDiscrimination' target too, because even though they can't reverse the damage they have done by insisting that Africans are irremediably promiscuous, the status of this claim as institutionalized racism will eventually become clear, at least to those who are prepared to think the issue through a little (a surprisingly small number of people so far).

After all, reducing 'sexual transmission' is one of their stated goals, whereas UNAIDS has barely breathed a word about transmission through unsafe healthcare in their 20 year, multibillion dollar, celebrity studded reign. They could just quietly (imperceptibly, even) reveal some changes in the way figures are collected and next December 1, a re-estimation of non-sexual transmission of HIV could be the subject most deserving of their customary (spontaneous) standing ovation module.

UNAIDS are uncharacteristically frank about mass male circumcision, which is something of an embarrassing fiasco: "As of December 2012, 3.2 million African men had been circumcised [...]. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011. Still, it is clear that reaching the estimated target number of 20 million in 2015 will require a dramatic acceleration." (They don't say how many of the 3.2 million circumcised over quite a few years would have been circumcised anyway but took advantage of the free (anesthetized) operation.) Might this spell an unobtrusive retreat from this dangerous imperialist program?

But one of the heftiest pieces of bullshit in the 'report' (and there is stiff competition) is about "the goal of providing antiretroviral therapy to 15 million people by 2015". They say that "As of December 2012, an estimated 9.7 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.6 million over 2011. That brings the world nearly two-thirds of the way towards the 2015 target of 15 million people accessing antiretroviral treatment."

The difference between UNAIDS' claim and the truth is expressed in a few words, such as 'were receiving' therapy. If they said that 9.7 million people had been recruited on to a therapy program, that might have been true (or somewhat closer to the truth). But 9.7 million is, at best, the number of people who have at one time been put on a program. Neither UNAIDS, WHO, PEPFAR, CDC nor anyone else knows how many of those 9.7 million ever took the drugs, or for how long, how many dropped out of the program, how many were recruited on to two or more programs or simply died, etc.

No one knows, and no one really cares because 9.7 million is an impressive figure, and it sounds like a good attempt at the 15 million target. There is not much incentive to estimate how many people are alive and on antiretroviral treatment, indeed, such an estimate could prove fatal to several substantial institutions (not just UNAIDS, which seems to thrive on failure to achieve anything at all, aside from spending money and institutionalizing bigotry). Is the true figure 8 million people, 7 million, or some far lower number? Billions of dollars say that no one is going to ask this impertinent question (unless they are not in receipt of any of those billions, and never will be).

Unsafe healthcare does exist in extremely poor, high HIV prevalence countries, surprising as that may seem to those who are used to the mainstream view that HIV is hardly ever transmitted through heterosexual sex in every country in the world, but almost always transmitted through heterosexual sex in a handful of African countries. What contribution does unsafe healthcare make to the worst HIV epidemics in the world, all in sub-Saharan Africa? Would it be the one or two percent UNAIDS grudgingly suggests, or something far higher? We don't know yet. No billions have been offered for the answer to this question.

Using cumulative figures is great, because you get that great 'step' effect when you produce bar graphs, and there is nothing like comforting, progressive steps to convince people that everything is good in UNAIDSland, and in the HIV industry in general. A very achievable 2015 target would be the abolition of UNAIDS and the promotion of safe healthcare. Because unsafe healthcare risks the spread of HIV, something UNAIDS has never got around to accepting. But I suspect that instead, there will be a continuation of the finger-pointing and victim-blaming that has characterized the mainstream approach to HIV in high prevalence countries so far.

Could PrEP be in Competition with Mass Male Circumcision Programs?

[Reposted from the Pre-Exposure Prophylaxis (PrEP) Blog]

After years of trying to create a market for pre-exposure prophylaxis (PrEP) pills, such as Truvada, Big Pharma has turned to their favorite mass marketing ploy: dumping their products in African countries that are starved of health funding. Of course, why wouldn't they dump them in Africa, won't they be paid for with donor funding?

An article in Kenya's The Star entitled "Kenya: 'Wonder Pill' for Risky Sex On the Way" takes the unusual step of raising some difficult questions about PrEP, rather than repeating the Big Pharma press release, despite a shaky introduction. The article continues "Kenyans involved in risky sex behaviours will soon get a 'wonder pill' that can prevent HIV infections. Experts say Truvada, which some call the 'new condom', can reduce chances of catching HIV but there are fears the drug may be misused by the youth".

What, exactly, would constitute misuse of the drug? If it can cut the risk of infection by "up to 75 per cent if one faithfully swallows it daily", what could go wrong? Well, as the article eventually reveals, most people don't swallow drugs daily and most people can not expect 'up to 75%' reduction in risk. That figure is not even from a randomized controlled trial, but from a 'sub-group' study, where the best results are used to exaggerate the level of protection people, in (comparatively) strict trial conditions, may expect. Outside of that sub-group, and outside of drug trial conditions, risk reduction is far lower.

It's odd that such reports talk about studies and proofs for something that they then refer to as a 'wonder pill', a 'new condom' and talk of 'up to 75% protection' (although that's a bit weak compared to the term 'invisible condom' used by those marketing mass male circumcision), and the like. These are PR buzzwords, not scientific findings.

It is said that PrEP programs intend identifying those most at risk of being infected, such as sex workers, intravenous drug users and men who have sex with men. This will be a departure from vilifying these already stigmatized and criminalized groups; it remains to be seen how much donor funding will actually be spent on these groups to provide them with PrEP, given that it has been so difficult in the past to provide them with condoms, injecting equipment and even basic sex and sexuality education.

As the article says, Truvada is expensive, and it has made billions of dollars for Gilead. So it's worth their while pushing as much of the stuff as possible in countries with high HIV prevalence while the patent guarantees that their product will face little competition. By the time the patent expires the likes of Bills Clinton and Gates will surely have set up some program whereby the drugs can continue to be purchased at inflated prices.

The article makes the important point that nearly 1 million HIV positive Kenyans currently need antiroviral drugs just to keep them alive. So why would donors want to provide these same drugs to people who are not yet infected with HIV (aside from an obvious desire to enrich big pharma)?

Oddly enough, a cost effectiveness study makes its estimates using existing levels of male circumcision and antiretroviral therapy. This means that the three multi-billion dollar programs will be in direct competition with each other for funding, and each one will be trying to claim that any drop in HIV incidence is a result of their work. The study also seems to assume far higher levels of success than have been achieved so far. But that's big pharma for you.

While Gilead and other pharmaceuticals can gain a lot from any increase in antiretroviral therapy and PrEP programs, they may not stand to gain from mass male circumcision programs. Their assumption that their PrEP programs will be cost effective only in countries where circumcision levels are low suggests that by the time their product may be approved, the circumcision programs will already need to have failed, some time around 2015.

Worries that people may use PrEP as a kind of recreational drug, so they can dispense with the use of condoms when they are engaging in sex with people who may face a high risk of being HIV positive are not very convincingly addressed; nor are worries that overuse and misuse of antiretrovirals, either for HIV positive people or as PrEP, are brushed aside, with remarks about "government policy" and making the drug available "in form of a package that probably includes HIV testing and other prevention methods".

I seem to remember condoms, circumcision, ABC and various other programs being made available in the form of a package, without that leading to extraordinary results. But it will be interesting to see if PrEP will erode some of the funding currently being made available to, or earmarked for, mass male circumcision programs.

Circumcision programs stand to rake in billions for the big providers, but widespread use of PrEP would be worth far more. It's unlikely that a full scale version of both programs could co-exist; they are not mutually exclusive, but their cost effectiveness is predicated on their being the only or the main program in high HIV prevalence countries.

Whether one program displaces another, or whether they all get funded, the losers will be people in high HIV prevalence African countries, which will continue to suffer from under-funded health and education sectors. They will continue to be a mere 'territory' for sales reps, who will continue to carve things up in ways that should be very familiar to us by now.

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?

Misinformation from UNAIDS' flawed Modes of Transmission model

[By Dr David Gissselquist - Cross-posted from the 'Don't Get Stuck With HIV' website and blog]

To defeat HIV/AIDS in Africa, UNAIDS recommends: “Know your epidemic.” The best way to do so is to investigate to trace the source of infections – especially in children with HIV-negative mothers, virgins, and married people with HIV-negative spouses and no outside partners.

But that’s not what UNAIDS urges African governments to do. Instead, UNAIDS urges governments to use its Modes of Transmission (MOT) model to estimate numbers of infections from various risks.

But the MOT model contains a glaring error. Because of this error, whoever uses the model ends up estimating far too many infections coming from spouse-to-spouse transmission.

In Uganda, for example, the MOT model estimates that 60,948 married adults got HIV from their spouses during 2008. This is two-thirds of the model’s estimated total new infections from all risks in Uganda in 2008.

The MOT model got this number by supposing that 5.9% of married adults (421,000 adults) were HIV-negative with HIV-positive spouses, and that 14.5% of these spouses at risk got HIV from husbands or wives in 2008 (60,948 = 14.5% x 421,000).

But the number of spouses at risk is far, far less. Uganda’s 2004/5 HIV/AIDS Sero-behavioral Survey reports that 6.2% of husbands and 5.2% of wives were HIV-positive.  But – and this is the important fact the MOT model ignored – most HIV-positive husbands and wives were married to each other. Only 2.8% of wives and 1.8% of husbands were HIV-negative with HIV-positive spouses.

Overall only about 2.3% of married adults (averaging 2.8% of wives and 1.8% of husbands) were HIV-negative with HIV-positive spouses – only 222,000 vs. the 421,000 estimated in the MOT model. If 14.5% of these 222,000 adults got HIV from their spouses in a year, that would account for 32,100 new infections (14.5% x 222,000), far less than the 60,948 estimated in the MOT model.

Why is this important? Because if fewer infections are coming from spouses, how did so many Ugandans get HIV in 2008? In other words, the MOT not only over-estimates HIV from spouses, but also underestimates infections from other risks.

What risks are underestimated? Hold on now! Don’t run away with sexual fantasies about young people and some married adults having too much fun with non-spousal partners. Indulging in racist and stigmatizing sexual fantasies is something too many official AIDS experts like to do. But the evidence does not support such fantasies. The best information on sexual behavior does not come close to explaining Uganda’s epidemic.

Setting aside sexual fantasies, the underestimated risks are more likely to be those that UNAIDS’ staff and other health professionals want to ignore – skin-piercing procedures with unsterile instruments, such as injections, dental care, manicures, etc. This is true not only in Uganda but also in more than 15 other African countries that have used the MOT model to get ridiculous figures on numbers of HIV infections from spouses.

Remember how we began: The best way to “know your epidemic” is to trace infections. Let’s challenge HIV/AIDS researchers -- finally -- to do their job. Although it’s decades too late, tracing is still needed to find all the important risks and to stop Africa’s generalized HIV/AIDS epidemics.

[Note: This blog summarizes evidence and arguments in: Gisselquist D. UNAIDS' Modes of Transmission model misinforms HIV prevention efforts in Africa’s generalized epidemics, available at:  http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2315554.]

Maternal Health Care a Significant HIV Risk in Ethiopia

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

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I'd like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It's not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various 'initiatives' aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting 'cheaters'. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be 'cheaters' could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It's certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don't know they are infected. It must also be remembered that most people don't realize that there are significant non-sexual risks; if they don't know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people's worries in countries like Ethiopia, but only because many people don't attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

PrePex at Loggerheads with Main Recipients of Circumcision Funding?

Only a few weeks ago, the owners of the company that makes PrePex 'bloodless' circumcision devices (effectively, a plastic ring and a rubber band) were happily plugging their ware, a difficult process of persuading journalists to regurgitate an entire press release without any research or criticism. This time, the press release was set in Uganda and a researcher, presumably one not versed in the skills of PR, claimed that "We have so far tested it on about 50 clients but we need 250 more to confirm its acceptability but so far it has worked properly with those who used it". No need for any Ugandans to worry, then.

But alas, some of the main proponents of circumcision, who are also some of the main recipients of the copious millions of dollars available for the mass male circumcision programs in Africa, have announced that "The PrePex Device Is Unlikely to Achieve Cost-Savings Compared to the Forceps-Guided Method in Male Circumcision Programs in Sub-Saharan Africa". They were even generous enough to make the findings available in a free peer-reviewed source. This is all the more remarkable when you consider how most research relating to mass male circumcision is made available: selectively, at the convenience of those who collected the data, rather than that of anyone who may wish to scrutinize it.

Of course, this may be just a bit of a spat between those who prefer to know that scalpels are used (who currently receive the lion's share of funding) and those who don't give a toss how the operation is carried out as long as they make lots of money out of it. The paper by Walter Obiero, Marisa Young and Robert Bailey claims that at $45-50, the PrePex method is "unlikely to result in significant cost-savings". The authors declare no competing interest, unless the fact that at least one of them is a founder of the Nyanza Reproductive Health Society, which provided some of the funding for the research, represents some kind of competing interest.

The $45-50 figure is interesting. According to an article from the UK's National Secular Society, hospitals in Sheffield are going to start charging for non-medical circumcision. They carry out fewer than 200 per year, which is surprising enough, but they expect to save nearly $1,600 per operation. Could it really cost 32 times more to carry out a circumcision in an English hospital? I can imagine costs are lower in African countries, for lots of reasons, but I wonder what, exactly, will be excluded from the mass circumcision campaigns to keep the costs so low. I wonder also if Sheffield could be induced to reconsider their decision if they could offer the operation so cheaply, and how many people would then take them up on it.

One person commenting on Sheffield's decision feels that this may give rise to 'backstreet operations'. But in African countries where circumcision is already carried out for tribal reasons, almost all circumcisions are 'backstreet operations', carried out by someone with no medical training, often without sterile instruments. The several billion dollars on offer for mass male circumcision programs in African countries are mainly available in areas where circumcision is not routinely carried out already.

A spokesperson for the National Health Service said: "Non-therapeutic circumcisions are not clinical interventions and as a group, we would not want anybody to undergo a medical procedure if there was no specific clinical need." A spokesperson for the National Secular Society said "We believe that non-therapeutic circumcision should not be permitted until the boy is old enough to give informed consent." These guys have evidently never heard about the US government's plans for African males.

Most articles promoting mass male circumcision for high HIV prevalence African countries claim that "results from three trials in sub-Saharan Africa, including one from Rakai, Uganda, showed that circumcision could reduce HIV transmission from positive women to negative male partners by up to 60 percent". This is not what the trials showed. HIV transmission was lower in the group that was circumcised than in the group that was not. But the trial did not show that all transmission was a result of sexual contact. Some may have been through unsterile healthcare, reused medical equipment, etc. Perhaps more importantly, at least one of the trials suggests that HIV transmission increased in the control group, rather than decreasing in the intervention group.

It seems hard to believe that current interest in promoting mass male circumcision to reduce HIV transmission from females to males could be based entirely on the evidence for the effectiveness of such a strategy, because the evidence is extremely mixed so far. It seems equally hard to believe that the whole thing is just a money earner for those competing for funding. But there is a lot of money involved. You might expect the Nyanza Reproductive Health Society to be unworried about whether PrePex is used, or some other method. But the difference in cost could be about 10%, some $100,000,000. So how much does something have to be worth to be a 'competing interest'?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Mass Male Circumcision: it's Not Done in Europe, So Why do we Tolerate it in Africa?

The current plan to circumcise 20 million African adults and countless millions of African infants arose purely from the prevailing view that HIV is almost always transmitted sexually in African countries. If we had tested that view years ago and modified it appropriately in the light of available evidence, the issue of aggressively promoting circumcision and spending billions of dollars of 'aid' money on it would never have arisen. It would have been clear that HIV is not exclusively transmitted through sexual contact, that it is also transmitted through unsafe healthcare, cosmetic and traditional practices.

If circumcision reduces HIV transmission, it could only reduce sexual transmission, not transmission through other modes. It is also only claimed to reduce sexual transmission from females to males; it may increase transmission from males to females and, given that prevalence is higher, often much higher among females in African countries, this may result in circumcision programs increasing HIV transmission overall. In addition, African countries' crumbling health systems would not be able to provide tens of millions of safe male circumcisions; the most basic health services are denied to most people and available services are known to be very unsafe.

We have privileged HIV above all other diseases and we have privileged sexual transmission above all other modes of transmission. By doing this, we have stigmatized every African as sexually promiscuous and every HIV positive African as paying the price for their own behavior; yet we fail to acknowledge that HIV is not always transmitted sexually. So why are circumcisions now carried out so readily in countries where most other kinds of operation and medical procedure are unavailable? Even where other procedures may save people's lives, disproportionate amounts of money are spent on sexually transmitted HIV, including in areas where HIV is certainly not the highest priority, sometimes not even a low priority.

Therefore, in the interest of safe healthcare for all, it is necessary to oppose mass male circumcision programs. They will not reduce HIV transmission much, if at all; they will not be carried out in contexts where safe healthcare is generally available; and they will be carried out in countries where the most common causes of illness and death are generally ignored, despite being far higher priorities than HIV or sexual health. For example, there is an urgent need to address reproductive health more broadly, the overall health of women, infants and children and the health of men who are not HIV positive, nor at risk of being infected through their sexual behavior. Diseases that relate to living conditions, such as TB, that infect far more people than in countries where living conditions are better, also need to be addressed. There are also water-borne diseases that infect, debilitate and kill millions because of lack of access to clean water and sanitation.

HIV needs to be put in perspective; it is a virus, one of many, sometimes sexually transmitted, sometimes non-sexually transmitted. We don't even have any idea of the extent of non-sexual transmission, so we can neither tell how much transmission mass male circumcision could avert, if any, nor can we tell how many people are likely to be infected and/or to infect others as a result of the circumcision programs. Mass male circumcision is part of a much bigger picture, and it's because the bigger picture of HIV is distorted by Western obsession with 'African' sexual behavior that we've ended up with something as stupid as mass male circumcision. People are being denied their right to health care, to safe healthcare, to bodily integrity and to many other things. Circumcision is just one problem and the mass male circumcision problem grew out of our failure to address non-sexually transmitted HIV, safe healthcare and all the more important development areas in developing countries.

I am not an 'intactivist' and I don't advocate for 'intactivism', not because genital integrity is too small or too unimportant an issue; it's because it is just a part of a much bigger picture. Most human rights are being denied in some developing countries, not just a handful of rights. Genital integrity is just a part of something that is too big to ignore: bodily integrity and the other human rights that are being denied to those who are denied their right to bodily integrity. Circumcision itself may do harm, it may do good, it may do nothing. But it is the aggressive promotion of mass male circumcision programs in places where most forms of healthcare are unavailable and most available healthcare is not safe that is most objectionable.

If anyone tells you that healthcare services fail people in high HIV prevalence countries because of stigma, health seeking behaviors, culture, education, tradition, or anything else, remember that healthcare services are far more likely to fail because they are not available to most people; where they are available, they are likely to be unsafe. This is not to say that stigma is not an issue, but it is one that arises from the view, mentioned above, that HIV is almost always transmitted through heterosexual sex in African countries. Education also fails people, and not just in relation to health. Health seeking behaviors, culture, tradition and other issues may well be important issues. But they are of less importance where access to healthcare is poor and where that healthcare is not safe.

Despite lengthy (and lucrative) campaigns telling us that everyone is at equal risk of being infected with HIV, that HIV is an 'equal opportunities' virus, that it's all about sexual behavior, etc, it has long been clear that risk is most definitely not 'equal'. Both men and women who are receptive sexual partners face a very high sexual risk. Men who only engage in insertive sex (i.e. most heterosexual men) and who have no other risks are very unlikely to become infected, so women face higher sexual risks than men. Intravenous drug use is the second biggest risk in most rich countries. But the extent of non-sexual infection through unsafe healthcare, cosmetic and traditional practices in high HIV prevalence countries is not well known and is often not even acknowledged.

In wealthy countries circumcision stands out as an anomaly, where female genital mutilation (FGM) is viewed as a denial of the right to bodily integrity. We don't need to argue against FGM on the grounds that it causes physical (and psychological) damage, or that it may present problems later on in life. The fact that there is a right to bodily integrity is enough, but the anomaly stems from the fact that male circumcision is not seen as a denial of the right to bodily integrity. Some argue for male circumcision as a religious or cultural right, and that is not a problem, as long as it is the adult individual who makes the decision, not the parent.

But in developing countries, there is nothing anomalous about programs funded by Western governments telling people what is good for their health, regardless of broken down and unsafe health facilities, cultural and religious practices, or even human rights. FGM is opposed on grounds that should also be used to argue against male circumcision, yet male circumcision is promoted with the claim that it reduces sexual transmission of a virus, in the full knowledge that the virus is not always transmitted sexually and that it may be transmitted through circumcision itself. Western countries were once opposed to breastfeeding. Indeed, it may have been Western churches that once opposed circumcision in parts of Africa, or at least deemed it unnecessary for people who had been converted to Western religions. Claimed health benefits do not justify mass male circumcision programs.

In developing countries, circumcision is just one issue out of many, the tip of the iceberg. If we were to forget circumcision and concentrate all our attention on some other issue tomorrow no one would be any worse off. Singling out HIV, circumcision or any other issue, divorced from the context that gives rise to the issue, is part of the problem. If we didn't believe the lie that HIV is almost always transmitted sexually in African countries, we wouldn't even be questioning the wisdom of mass male circumcision, and those promoting it would not have received billions of dollars to ride roughshod over African people.

If it was decided that some other kind of intervention reduced HIV transmission, such as giving HIV positive people ARVs long before there is a clinical benefit (it's called Treatment as Prevention) or giving HIV negative people ARVs because they have or may have a HIV positive partner (it's called PrEP, pre-exposure prophylaxis) or give lifelong ARV treatment to pregnant women, rather than a short course of ARVs (it's called B+), those may become as aggressively promoted as circumcision. Sadly, all three of these are already being aggressively promoted even though the net benefit may be low and there may be very serious consequences in terms of transmission rates and health more broadly.

We don't have to do research to know that people need safe healthcare, education, infrastructure and the like, but we seem to avoid getting involved in these basic human rights and instead allude to things like corruption and culture and whatever else journalists and academics tell us is pertinent. Mass male circumcision programs are not wrong because they won't work or because circumcision reduces sensitivity or has anything else to do with sex or the penis. They are wrong because people have a right to bodily integrity, to safe healthcare and to many other things that are currently denied to them.

This is not merely a logical or academic argument against circumcision; we know that we couldn't carry out such programs on our own fellow country people, regardless of any claimed benefits, public health or otherwise; so why are we even discussing doing so in African countries? Aggressive promotion of mass male circumcision programs in African countries, mainly funded and carried out using US money, has got to stop.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]