Back in Isiolo

Photo: Isiolo Youth Against Aids and Poverty (IYAP), setting up camp to provide mobile voluntary HIV counselling and testing (VCT) services in Isiolo town centre.

The trip to Isiolo is, in itself, a culture shock. The bus is always a buzz of conversation and loud music and the roads could be the source of hundreds of road movie anecdotes. I know the 14 seater minibuses here, called matatus, have a reputation for taking risks. But I saw one that had "14 Gamblers" painted on the door, instead of "14 Passengers". Aki Kaurismaki really should make a movie here.

Anyhow, the town of Isiolo no less disappointing. It was still hot, thought the sun was going down, and a constant, gusty wind drove up mini dust devils and covered everything in a thick, gritty film. But I was there to see IYAP, the Isiolo Youth Against Aids and Poverty, who were running a mobile voluntary HIV counselling and testing (VCT) clinic in the town centre.

Mobile clinics have been very successful, compared to the static clinics, which most people seem to avoid. It costs more money and requires more work to go out and set up a camp where people can visit for VCT services. But it is worth it and the IYAP team can test 60 or 70 people in a day. And they are not confined to the town, they can also visit distant villages and rural settlements.

A short while ago, IYAP was also able to do what they call "moonlight testing", whereby they go out at night and set up camp. Many people who are reluctant to go during the day seem happy to turn up for the moonlight sessions. Many of them are people who work at night or who are out at the pubs and clubs.

However, there have been terrible food and water shortages in and around Isiolo and many other parts of Kenya. This has had a knock on effect on security and has resulted in tribal clashes. Many people have been injured and some have been killed, farms have been damaged, stock has been stolen and destroyed. Hopefully, government efforts to reduce food insecurity and civil disturbances will alleviate things soon.

IYAP have many plans for the future, which they will be writing about in their forthcoming blog. I'll post up some further details about my visit here in the next few days and also, the URL for the new IYAP blog.

Return Visits to Kibera and Isiolo

Photo: Work in progress on the new Kibera School for Girls

It's good to be back in Kenya again, despite all the bad news I keep hearing. And I have heard some good news too. I went to see a Kibera based organisation called SHOFCO, who work with young people and HIV positive women. Their founder, Kennedy Odede, has attracted a lot of funding while on a scholarship in the US and they are busy building a school and a maternal health clinic. When I went to visit them some time ago they were unable to do much due to lack of funding but they are really flourishing now.

Meanwhile, quite a number of people have died of hunger related conditions in the past few months in Kenya. Drought and food shortages continue and many more are suffering from the effects of extreme hunger and malnutrition. Even in areas where food is being distributed, the unbalanced, high-starch diet contributes to malnutrition related diseases.

Friends in Isiolo have told me that the drought has meant that people need to move their livestock many kilometres in order to find water and grazing. This leaves their families very vulnerable to the attacks by bandits, which have become more frequent recently. In particular, a group of HIV positive women, who joined together to buy goods and livestock, have lost some of their livestock to bandits.

Eastern and North Eastern provinces, where much of the extreme poverty and food shortages occur, are somewhat isolated from the very centralised Kenyan administration. They are far away enough for most politicians to forget about them until it comes to electioneering. Then, small gifts can be distributed until votes have been safely cast.

These areas have also long been ignored when it comes to HIV related programmes because HIV prevalence is relatively low and people are not seen as being 'high risk'. This oversight is slowly being corrected, but for many years, HIV was spreading, albeit slowly. Populations are not dense but many of the people are very mobile, having to move around seeking pasture, water and trade.

I'm looking forward to visiting my friends in Isiolo who run IYAP (Isiolo Youth Against Poverty) this week. Hopefully I'll have more and better news then.


Photo: IYAP go out into the streets to attract people to be tested for HIV but this service is being compromised by the current security situation.

Use Condoms and Get Tested, Regularly

Uganda has launched a new HIV/Aids campaign, ‘Stay Negative and Love Condoms’. That’s good to hear because condoms are vital for preventing HIV. There are lots of other things that can be done but a campaign that highlights the use of condoms is certainly preferable to ones where abstinence and faithfulness are stressed and condoms hardly mentioned. It’s also good to hear that some effort is being put into preventing transmission of HIV, rather than concentrating mainly on people who are already infected. The Aids Healthcare Foundation is running the programme so I’ll be watching out for further information on it.

In addition to emphasizing abstinence and faithfulness at the expense of prevention strategies that have any chance of working, the Ugandan government hasn’t been pulling its weight in its HIV prevention efforts. Research shows that people’s sexual behaviour is not very heavily influenced by recent campaigns for safer sex. Perhaps now they will look beyond sex, at people’s livelihoods and circumstances, which determine when, where, how often and with whom people have sex. While they are at it, they could work on their attitude towards men who have sex with men (MSM).

Currently MSMs are pretty much ignored by HIV prevention campaigns and they continue to be the victims of persecution and abuse. They are a very high risk group and this abuse only makes matters worse. They need the protection of the law and access to health services. As do commercial sex workers and intravenous drug users. Criminalization and the continued refusal to engage in meaningful harm-reduction efforts for these groups are senseless and appears to be motivated by political or religious interests (if these are in any way different).

Indeed, many countries are considering some kind of law making it a crime to knowingly transmit HIV. People who are infected with HIV need to be identified by voluntary testing, not hounded and criminalized. In addition to the use of condoms, testing is a vital and effective tool in HIV prevention and care. People need to be encouraged to test, not threatened with a prison sentence if they turn out to be HIV positive. This sort of law is particularly hard on women, who are more likely to test at an earlier stage in the disease. The more people who test early and regularly, the better.

It is things like stigma, persecution, gender and economic inequalities, poor legislation and enforcement, corruption and political and religious interference that have allowed HIV to spread rapidly in many countries. These problems are, in most countries, getting worse. This is not the time to pass laws that make HIV eradication even less likely than it is at present.

Use Condoms, get tested, regularly, be careful and advocate against discriminatory and harmful laws.

Clinton, the Pot and the Kettle

Hillary Clinton is in Kenya, lecturing people about democracy and accountability and various other things that the US is hardly in a position to moralize about. She wants the Kenyan government to set up a tribunal to try those involved in the civil disturbances following the elections last year. Well, who doesn’t? Everyone, except those with something to hide or something to gain, wants justice, wants the people involved to be punished, wants the simmering violence that still goes on to stop, wants a stable government.

But when will the US administration be brought to account for the lies that resulted in several countries wiping out hundreds of thousands of Iraqi civilians? Many of the people involved are currently in comfortable positions, doing very well for themselves. Several multinationals have made enormous profits from the Iraq war and various other wars that have been started and stoked up by the US. Will they, one day, be brought to justice? I doubt it.

What sort of moral authority does the US have, given the part they played in most of the serious wars of the twentieth century? The Kenyan government has always been very cosy with the West and with the US in particular. When fighting broke out after the 2007/08 elections, news reports remarked on how surprising it was that such a thing could happen in Kenya, which had been so peaceful before. An estimated 500 people were assassinated in extra-judicial killings in the six months prior to the election. The West just chose to ignore these events.

As for suggesting that politicians and other parties should be sent to the International Criminal Court (ICC), how are the Americans in a position to be insisting on this? They (somebody called Clinton, actually) reluctantly signed up to the ICC but it was never ratified and this signature was quickly suspended under the Bush administration. Since then, the US has got most countries to sign bilateral immunity agreements so they cannot be prosecuted by the court. The last country that should be pushing anyone into the ICC is America.

I notice Clinton is also going to South Africa, Angola, Congo and Nigeria, countries as well known for their human rights records as for their vast mineral and oil wealth. Is it cynical of me to doubt the motives of Clinton and the US? If it is cynical to criticize cynicism, then I am guilty of cynicism. Mr William Samoei Ruto, who is one of the people implicated in the post election violence, is reported to have told Clinton that he has not yet been trained by the US. But I think he has learned a lot about impunity from them.

Why are we so Averse to Basic Needs?

Further to earlier postings on this blog about mass male circumcision (MMC) as a strategy to reduce HIV transmission, a recent mathematical model shows that the use of condoms and antiretroviral therapy (ART) would have a far greater impact. The data used was for South Africa so it does not necessarily apply directly to other African countries.

The lead researcher expressed surprise at how little effect MMC would have. I have long been curious to know why anyone would think MMC would have such a profound effect. In Kenya, where there has been much talk of MMC, circumcision rates are already much higher than in South Africa, so they have even less to gain from such a strategy.

The percentage of people on ART in Kenya is also higher, as is condom use, though they are nowhere near as high as they need to be. But this paper gives a lot of support to people who are questioning the wisdom of rolling out MMC as a HIV reduction strategy for developing countries.

The results are preliminary but it is good to see the MMC orthodoxy challenged and found wanting.

Meanwhile, I have also raised questions about proposals to test everyone and treat everyone found to be HIV positive. Another piece of mathematical modelling shows that if such a strategy were to be implemented in Washington, DC (which has the highest HIV prevalence in the developed world), it would be unlikely to halt the epidemic.

Even assuming that 100% of people were tested, that they returned to be tested at regular intervals and that anyone found to be HIV positive was put on ART immediately, HIV transmission would not be reduced enough to eradicate the disease and the rate of transmission would eventually return to present levels. And these are big assumptions.

Again, these results would not be directly applicable to African countries such as Kenya. But one the main problems in Africa would be the difficulty of getting large numbers of people, not just to test, but to test regularly. There would also be the problem of getting large numbers of people on treatment and keeping them on treatment in countries that are seriously resource poor.

There is plenty of evidence to show that reasonable standards of health, education, infrastructure, water and sanitation and other social services would have a great impact on all diseases, not just HIV. People need assured livelihoods, food security and good governance. No large scale, expensive and high technology HIV intervention will have much impact until all these other issues are addressed.

Don't Wait for Big Pharma to Respect Human Rights

The Science and Development Network has an article commending the Brazilian government on its strategy for tackling HIV and AIDS. The country approached pharmaceutical companies in 2000, which is some time ago, and tried to put pressure on them to lower their prices. They made it clear that they could issue compulsory licences for Brazilian companies to produce generic versions of antiretroviral drugs that were still under patent.

This worked very well and the prices of drugs came down considerably. Brazil produced and imported some of the generic versions of drugs they needed. This is why the country was able to roll out antiretroviral therapy (ART) for everyone who needed it. Campaigners may have been fighting for the rights of people with HIV and AIDS but the real clincher seems to have been a threat to big pharma's ability to screw as much money out of people as possible.

Kenya is not as wealthy as Brazil and most of their money for ART comes from donors. However, far from producing or importing generic ART drugs, Kenya has passed a bill that makes it unlikely that generic drugs can be imported because the law is now fuzzy enough not to distinguish between generics and fakes. It would seem that the Kenyan government did this for the benefit of pharmaceutical companies rather than for the benefit of Kenyans.

I am surprised that donors are content to pay for overpriced drugs rather than putting some of the money into giving Kenya the capacity to produce generic versions of the drugs they need. In the long run, large scale rollout of ART will not be sustainable unless the price paid for the drugs comes down. If Kenya were to produce their own, that would go a long way towards making rollout sustainable and even feasible.

Around 30% of people requiring ART are currently receiving treatment. The plan is to have 100% of people on treatment by 2010. The number of people becoming infected with HIV continues to exceed the number of people being put on treatment. There are also plans to put people on treatment earlier, which will further raise the costs of the national treatment effort.

It's not that there isn't enough money, it's just that too much money is being charged for pharmaceutical products. This is a political and human rights battle and at present, Kenya is on the side of big multinational pharmaceutical companies, fighting for commercial interests and opposing Kenyan people's human rights.

Healthy People Have Needs Too

The aim to roll out antiretroviral treatment (ART) for everyone who needs it was always dogged by (usually tacit) questions about sustainability. In Uganda, for example, ART is 95% donor funded. For various reasons, much of that funding is now being reviewed or cut.

Many people who are put on ART will, sooner or later, need a course of second line drugs because of resistance to the first line drugs. This increases the cost of the drugs by 6 or even 10 times. And resistance can also develop to second line drugs.

The drugs themselves are only one cost involved in treatment but as the drug companies are getting the lion's share of HIV related money, there is little pressure for money to be spent on other treatment costs. The fact that the drugs are bought, paid for and delivered to the country in question doesn't mean that the country has the capacity to distribute them and actually treat people.

But the most unsustainable aspect of aiming for universal ART rollout is that little is being done to reduce the rate of new infections. The rate of new infections continues to exceed the number of people being put on treatment.

The trend towards putting people on ART earlier may have some impact on the rate of new infections. The idea of testing everyone and treating everyone found to be HIV positive may also have an impact. And the idea of putting everyone thought to be at risk of being exposed to HIV on ART, called pre-exposure prophylaxis or PrEP, should also reduce the rate of new infections further.

But all of these measures together will not cut HIV transmission to a sufficiently low level for the epidemic to be effectively eradicated. I know, mathematical modelling has shown that *if* around 80% of sexually active people opt for testing once a year, the epidemic could be more or less eradicated by 2050.

However, that’s a very big if. This sort of modelling has no bearing on the practicalities of how the sort of decrepit health and social service levels found in high prevalence countries will ever persuade large numbers of people to test regularly. At present, testing is between 10 and 20% of populations and that's after many years of trying to persuade people to test.

Epidemics are inherently unpredictable and we have been, consequently, fairly poor at predicting which direction the HIV epidemic will take. In the US, which hasn't lacked funding, high levels of circumcision and concentration on abstinence only education has resulted in the highest HIV prevalence in the developed world.

HIV spread rapidly in developing countries, especially among people in densely concentrated populations with low levels of education, health and social services and very high levels of gender and economic inequality. But well educated and wealthy people were, at least at one time, more at risk than poor and less well educated people.

Now, HIV is spreading in less densely populated areas and the effects of having such low levels of education, health and social services are clearly felt in that most HIV prevention efforts are failing. They are failing because, unsurprisingly, they require good education, health and social services; what a surprise!

Yes, people who are infected with HIV need to be treated, and they need a lot more than just drugs. They should be entitled to this treatment and care and that should also cut transmission considerably. But for widespread treatment to effectively cut transmission, we also need to target the people who are presently being infected with HIV and those who are at risk of being infected.

The process of identifying all infected people is too big a job to effect quickly enough to protect people who are presently uninfected. Targeting those who are presently uninfected means providing everyone with adequate health, education and social services. This means *not* spending all available money on drugs, mass male circumcision, PrEP, trying to test every sexually active person, etc, and providing people with the basics that they need just to survive.

I agree with those who are calling for more money for HIV but no amount of money will make up for the fact that people lack the most basic things. The current approach to HIV appears to assume that HIV is independent of the overall environments in which people live. HIV is not independent of each aspect of people’s day to day lives; no disease is. On the contrary, HIV is transmitted rapidly where people work and travel and behave much as they have been doing for as long as anyone can remember.

HIV transmission is reckoned to be low at the moment in Zimbabwe (although prevalence is high) because people’s day to day lives have been disrupted. The same thing is said to have happened in other countries that experienced wars and civil disturbances, such as Ethiopia and Angola. But that doesn’t mean that rates of HIV transmission will stay low in those countries.

Like all diseases, HIV is part of everyday life; it affects people who are rendered vulnerable by decades of falling public spending. A bigger chunk of the money needs to be spent on healthy people. I know that doesn’t fit in with the plans of the pharmaceutical companies and others who make a lot of money out of disease but healthy people need the means to stay healthy. If all the money is spent on drugs, healthy people will continue to suffer, as they are doing right now.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)