HIV Industry Withholding Vital Evidence

Some former sex workers in Uganda have set up an organization to represent sex workers , called the Women's Organization Network for Human Rights Advocacy (WONETHA). WONETHA believes that women who are involved in sex work should be supported as sex workers, rather than persuaded to change occupation. Trying to persuade sex workers to find another way of making money may be well intentioned (though it probably isn't). But in addition to not bothering to ask sex workers what they would like, such attempts fail to take into account the economic realities.

If you take a large number of women off the streets and give them other jobs, several things happen. Other women move into sex work, probably attracted by the higher price that sex work receives because there are fewer doing the work. Also, wages in the more conventional job market go down, as a result of more people looking for jobs and employers being able to pay even less than before. There are already lots of people doing some kind of subsistence or low paid work. It's often because they are so badly paid that they get into sex work in the first place.

People here have assured me that it is always possible to get a job or find some way of making money, that it is not necessary to resort to sex work. They don't seem to see that it is the fact that some people are not competing with them for these other jobs that makes it possible for them to find such work. Many other people, too, benefit from sex work, directly and indirectly. Police, security people in bars, clubs and hotels who get money from sex workers to allow them to do their work, other people who 'protect' sex workers or just bribe them, bar, club and hotel owners and various others.

Sex workers very often do look for alternative work, sooner or later. Many that I have spoken to have tried to work in the hospitality industry, to make money buying and selling things or by providing various services. But they often return to sex work, if they are not too old to do so, because there are already too many people trying to make money in these ways. The best thing civil society can do for sex workers is to advocate for better conditions for them, the protection of the law, access to safe medical services and full recognition of their human rights.

The motivation behind some of the efforts to persuade sex workers to give up sex work is the HIV epidemic, to which commercial sex work was said to have contributed greatly. Perhaps it did, though this is not clear. The most recent Modes of Transmission Survey for Uganda finds that sex workers, their clients and the partners of their clients contributed around 10% of new infections in 2008. Compared to this, over 40% of infections were from people in monogamous relationships. In other words, it is safe sex that is giving rise to a lot of HIV transmission, not unsafe sex.

The greatest contribution to HIV prevalence is said to come from people engaging in multiple partnerships and their partners. However, the percentage of people engaging in multiple partnerships is no higher in Uganda than it is in many Western countries and it is lower than in some. Very high rates of HIV transmission in Uganda are not explained by sexual behavior when the same behavior only results in very low transmission rates in other, more developed countries.

In the mid eighties, HIV prevalence among sex workers in Nairobi was found to be 81%. However, HIV rates, along with rates for other sexually transmitted infections (STI), began to fall over the next few years and continued to fall thereafter. And this happened in the absence of any HIV prevention programs. Whether earlier STI prevention vaccination programs had spread HIV among sex workers is debatable but such high rates among sex workers are unusual. In some countries, sex workers are unlikely to be HIV positive unless they are also intravenous drug users. So there is still a problem explaining why HIV rates are so much hither in developing countries than in developed countries.

Sex workers may face high risk of being infected with HIV and other STIs through their work. But they also face other risks that are much easier to avoid than sexual risks. For example, sex workers (and others) often use injectible contraceptives. They also regularly visit clinics for checkups and vaccinations against various STIs. If any of these clinics are reusing needles, syringes or any other equipment, a lot of infections could be transmitted by such unsafe practices. The Modes of Transmission Survey finds that 0.06% of HIV infections are transmitted in this way. But this figure is questionable in a country that has ongoing shortages of medicines, contraceptives, equipment, trained personnel and clinics.

Non-sexual HIV risks could be avoided but no one is going to avoid them if they don't know they exist. Sex workers are constantly being told about the risks they face through unsafe sex. But they are never told about the risks they face in clinics. Yet, they are being sent to these clinics in ever growing numbers. Sex workers have a right to know that HIV is not just transmitted sexually. Telling them about condoms and unsafe practices will not help them avoid non-sexual risks. And people who are not sex workers also need to know about non-sexual risks. They are quite mistaken in their belief that sex workers play a big part in transmitting HIV.

The most disgusting thing about the belief that HIV is almost always transmitted sexually in African countries is that it emanates from the HIV industry, which goes on about reducing stigma. There is no better way to promote stigma than to label people as 'most at risk', especially when they are known not to be most at risk. The HIV industry is well aware that unsafe medical practices can be far more efficient transmitters of HIV than unsafe sexual practices. And while they warn their own employees about these risks when they are visiting developing countries, they tell people who have to live in those countries that they needn't worry about injection safety or anything else that may result in exposure to contaminated blood.

Much of the stigma that sex workers and HIV positive people face is manufactured by the HIV industry, who know that non-sexual HIV transmission plays a part in the epidemic. They just don't want to admit that this phenomenon exists or to carry out any research that could reveal the exact contribution it makes to HIV epidemics in developing countries. Sex workers, HIV positive people, HIV negative people in developing countries and anyone concerned about human rights should be advocating for the right to know about something that represents such a huge threat to people's health and welfare. Until people know, they will not be able to protect themselves.

Will a New HIV Boss at WHO Make a Difference?

The World Health Organization (WHO) has a new head of HIV called Gottfried Hirnschall and he gave an interview recently to IRIN. Apparently he feels that, as a prevention message, abstinence is unrealistic. That's good, but not good enough. Abstinence didn't just fail because it's unrealistic. There's no reason why the option of choosing not to have sex under certain circumstances shouldn't be part of a comprehensive sex education program. It's just better if it's not called 'abstinence' and if it isn't the only trick in the box.

There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.

But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.

There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.

People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.

Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.

So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?

First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.

Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.

Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?

Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.

Don't Just Repeat the Mantra; Follow it!

One of the people who came up with the idea of a 'no sex month' to reduce HIV transmission by 10-45% (for that month) has published a paper which finds that neither poverty nor wealth drive the HIV epidemic. The no sex month idea suffers from what could be a major flaw: it will only reduce sexually transmitted HIV infection. That may sound obvious but this researcher assumes that most, perhaps even all HIV, is transmitted sexually. So his analysis of the finding that neither poverty nor wealth drive HIV is similarly flawed.

This latest paper may be more comprehensive than previous ones. But the suggestion that wealthy people are often more likely to be HIV positive than poorer people has been made a number of times over quite a few years. It has also been noted that higher levels of education can be correlated with higher rates of HIV. And it has been clear that these trends can change, with the correlation becoming less pronounced and even reversing over time. Whereas earlier in an epidemic, wealth and education may correlate with higher HIV rates, they may correlate with lower rates later on.

It has been clear also that HIV rates differ strongly among men and women, with prevalence among women being far higher than that among men at later stages in epidemics. Correlations between wealth and education are often stronger for women and less pronounced for men. And correlations can be stronger in poorer countries than in wealthier countries. So far, so good, these findings are all interesting and revealing. Before they were established, many pronouncements were made about connections between HIV and poverty and HIV and education which resulted in ineffective strategies.

But the paper's author links all these findings to the unspoken assumption that HIV is mostly transmitted through heterosexual intercourse, that the 'behavioral paradigm' is true. The extent to which HIV is transmitted sexually is not clear because the extent to which it could be transmitted non-sexually has never been properly investigated.

Many poor African countries have high HIV rates. But many richer African countries have even higher rates. Even within Kenya, the highest HIV rates are not found in the poorest areas. North Eastern province is by far the poorest province, with the worst education indicators, yet HIV prevalence is very low. Higher rates are found in Nairobi, whose population is richer and better educated, on the whole. But no matter how you slice up the population, high HIV prevalence does not correlate with wealth, poverty, inequality, education or anything else that is obvious.

If you assume that HIV is mostly transmitted sexually, you wonder why infections among women can be four times as high as those among men. Just who is infecting these women and under what circumstances? You could assuage these doubts somewhat by pointing out that women are more susceptible, for various different reasons. But then you find the richest women with the highest levels of education in Tanzania are far more likely to be infected than the poorest. This changes over time, but the trend certainly doesn't reverse. And the pattern among men is completely different. With the behavioral paradigm, you have to tie yourself in knots to understand just what sort of sexual behavior is going on here.

It helps if you are quite racist, which is lucky for UNAIDS because as an institution, they are racist through and through. It also doesn't do any harm to be sexist and UNAIDS also ticks that box. You then make up various different (and fairly improbable) hypothetical scenarios and you come up with this:

Poor people in some settings undertake particular risky practices – e.g. earlier sexual debut or reliance on transactional sex – whereas wealthy individuals may engage in other risky practices, such as participation in broader social and sexual networks or sex with higher numbers of (voluntary) regular partners.

It doesn't mean very much but it sounds good, especially as there are some citations in the original article, giving the whole thing a veneer of authenticity. But there is no evidence that Africans, rich or poor, male or female, engage in large enough amounts of the sorts of behavior considered risky enough to explain the devastating epidemics found in Sub-Saharan African countries. Sexual behavior varies from place to place, but not in the way UNAIDS and the author in question would like. Most Africans do not have lots of risky sex, only some do. But some Europeans do, as do some Americans. You just don't find HIV epidemics in Europe and America like the ones in Africa.

The author goes on :

Effective action requires unpacking the black box of behaviour by recognizing that HIV infection in poorer groups may arise from certain lifestyles and risky behaviours related to poverty, whereas HIV infection in wealthy groups may be due to different lifestyles and risky behaviours related to their wealth.

This may all be true but it is only true of sexually transmitted HIV.

If you don't assume the truth of the behavioral paradigm and you accept that some HIV is transmitted non-sexually, they you can consider less improbable and more testable scenarios. For example, you could look at the different behaviors of males and females relating to health care. Women could be exposed to more of the kinds of medical procedures and cosmetic procedures that might carry a risk of HIV infection. Richer women could be exposed to more of these procedures than poor women. Earlier on in the epidemic, education and wealth may have had little influence on women's attitudes towards health and cosmetic treatments but this could have changed as more became known about the epidemic.

If it is assumed that all or most HIV is transmitted sexually then you will end up with HIV prevention programs that aim to change people's sexual behavior. That's what we have ended up with, even worse, most of the programs don't work. Unless we also target non-sexual transmission, which means establishing its contribution to the HIV pandemic first, we will never 'know our epidemic', in the words of UNAIDS. And if we don't know our epidemic we will never 'know our response', either. The key to a mantra is not just to repeat it, you also have to follow it.

Individual Behavior Threatens National Security?

One often hears the term 'national security' being used in discussions about HIV/Aids. The epidemic is said to be threatening in a way that other epidemics are not, despite affecting fewer people than a lot of other diseases and health conditions. HIV/Aids is sometimes talked and written about as if it could topple governments or as if people from high prevalence countries could commit acts of aggression against low prevalence countries that would threaten security. There's a particularly interesting discussion of this phenomenon of the 'securitization' of HIV/Aids in relation to photo-journalism.

But I don't accept that HIV/Aids is an issue of national security. At least, I don't believe it is a threat to US national security, which is what most instances of the phrase seem to refer to. The argument is rarely that HIV/Aids is a threat to South African, Swazi, Kenyan or Botswanan national security, though it sometimes is. Even other rich countries don't seem to obsess so much about a specific national security threat from HIV/Aids. But use of the term seems to equivocate between referring to national and global security, almost as if they are the same thing.

It seems possible that the HIV/Aids pandemic, commonly framed as a threat that needs to be 'fought', becomes confused with the metaphor as used of diseases. Many diseases are said to threaten to attack us, that we need to defend ourselves, to fight back. People with a disease are said to fight it off, sometimes winning, sometimes not. Such metaphors are ubiquitous in talk about diseases of all kinds, whether infectious or not. The metaphor is fine until it starts to be taken a bit too literally.

But another thing that could be going on is that 'national security' is a convenient label, like 'terrorist', that you can slap on anything to support your claim that it is your business and that you have a right to interfere. Much of the funding for HIV/Aids over the past couple of decades seems to have been politically motivated and the fact that much of it was squandered on appeasing political and religious interests doesn't seem to bother the big donors. Health and disease don't seem to have been on the agenda, in reality.

I could understand if health, as a whole, were thought to be a potential matter of national security. But countries with high disease burdens and low standards of health care don't appear to have people fighting on the streets or invading other countries calling for these things to change. If the issue were denial of human rights, health being a human right, this might make it a matter of national security. But the big HIV/Aids donors have not shown much interest in health or in any other human rights. Some of the worst damage that the HIV/Aids pandemic has done has been to other areas of health, which have been almost completely ignored for over two decades. And the association of HIV with sex, sexuality, sex work and illicit drug use have done a lot of harm to decades of sexual, gender and racial equality movements.

If the pandemic were really an issue of national security, why is HIV prevention allocated such a small amount of money compared to HIV treatment and care? And why is HIV transmission seen as a matter of individual behavior, to be influenced, if at all, by an appeal to people to change their sexual habits, to avoid 'unsafe' sex or perhaps to avoid sex altogether? If HIV/Aids were really an issue of national security, surely reducing transmission would go beyond an appeal to individuals to modify their sexual behavior?

I recently mentioned a new fund called the Global Health Initiative, which is unusual in that it is specifically aimed at strengthening health systems in developing countries. Previous funds, such as PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global Fund, took the individual behavior change approach and even claimed that health systems were benefiting as a result of the work they were funding. Few critics believed this, but nor do those behind the Global Health Initiative, apparently.

Whereas the individual behavior change approach to HIV transmission seemed inimical to the 'national security' label, the perceived need to strengthen health systems could signal a renewed focus on HIV/Aids as a potential security threat. But that leaves me at a loss to know what to make of the Global Health Initiative. I think it's a good thing to see HIV transmission as going beyond the sexual behavior of individual people and to develop health systems. Health systems have been ignored for too long and this has clearly contributed to continued high levels of HIV transmission in many countries.

I just don't accept that HIV/Aids is a national security issue, or even a global security issue. I think the determinants of HIV, denial of human rights in the form of widespread poverty, poor living conditions, low levels of education and health care and crumbling infrastructures, could constitute issues of global security.

I don't think the Global Health Initiative is an admission, inadvertent or otherwise, that we have failed in our attempts to reverse the HIV pandemic. But if it reduces dependence on the individual sexual behavior theories of HIV transmission it may get us closer to working out exactly why some countries and some parts of some countries have such high levels of HIV. That should have been the first question that UNAIDS asked. But even if it's not the first, and even if UNAIDS are not asking it, it would still be good if it were taken seriously.

You've Been Bad: No Sex for a Month

One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.

This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.

So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.

There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.

Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.

The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.

More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.

If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?

Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.

Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.

The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.

Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.

The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.

Even WHO Admits Unsafe Injections are Ubiquitous

The dental unit of a hospital in Missouri has realised that 1,800 of its clients may have been exposed to diseases such as HIV and hepatitis B and C as a result of poor hygiene. All the people, apparently all war veterans, who may have been exposed, are being contacted and an investigation has been called for to find out how such an incident could occur. A political spokesperson has said that this is unacceptable for veterans. Whether he thinks it would be equally unacceptable for people who have spent no time in military service is unclear.

Still, it’s good to hear that there is a protocol, there is sterilization equipment and that someone is checking to see that the protocol is adhered to. It’s also reassuring that there are people who know that lack of care in using such equipment can give rise to infection risks and that if there is any possibility that clients are at risk, they can be and will be contacted and given a full check-up. Presumably, the staff involved will be retrained and those found to be responsible will be disciplined appropriately.

A similar occurrence in California resulted in 3,400 patients being contacted because they underwent a colonoscopy and it was found that correct hygiene precautions may not have been followed. And in the UK, 519 people have been contacted because a healthcare worker who may have treated them was found to be HIV positive. The worker, who has worked in a number of hospitals, has been moved to a role where there is no risk of blood contact.

The two American incidents are probably more worrying than the UK incident because patients are unlikely to be infected by HIV positive healthcare workers, in practice. But infections from unsafe medical procedures are thought to be common, especially in countries where there are low levels of training, staffing, safety and funding. The World Health Organisation (WHO) estimates that in some regions, up to 70% of the 16 billion injections given in transitional and developing countries are unnecessary. They estimate that up to 40% of injections worldwide are given with syringes or needles reused without sterilization and this could be as high as 70% in some countries.

One doctor in Kenya relates how he has stuck himself with needles on several occasions. He also says this is common among healthcare workers. However, the likelihood of a healthcare worker becoming infected is quite low, in practice. The biggest worry is of patients being infected by contaminated equipment. And this doctor says that they don’t always have enough needles, for children in particular. He describes how they improvise to get around this problem but also admits that this means the patient can be infected with hepatitis. He doesn’t mention HIV but presumably they are at risk from any blood borne disease.

This one medic can see up to 100 patients a day, as can many practicing healthcare workers in other facilities all over Kenya and East Africa. Doctors and other healthcare practitioners receive a lot of training but if they don’t have the equipment, they either need to ‘improvise’ or refuse to treat people. But what of all the other people who give injections and carry out other procedures that involve potential blood exposure? The risks may be lower but some of them only receive a few weeks training. And there are those with no training at all who also give injections, informal practitioners and the like.

UNAIDS ‘estimate’ that unsafe healthcare results in around 0.6% to 2.5% of HIV infections in Kenya. Yet the WHO estimate that globally, 2% of HIV infections are caused by unsafe injections. Is it really credible that countries with high prevalence of blood borne diseases and low levels of safety in healthcare settings could have such low transmission rates through unsafe medical procedures? WHO estimates that up to 9% of HIV infections may come from unsafe injections in South Asia. How could the figure be so much lower in African countries, where healthcare is known to be of a very low standard and prevalence of HIV is so much higher than it is anywhere in Asia?

In the US and the UK, where there is a relatively small risk that people will be infected with HIV as a result of medical procedures, hundreds, even thousands of people are screened to make sure that they were not infected. But in developing countries, where HIV prevalence is high, we are told that most HIV transmission is through heterosexual sex and therefore transmission through unsafe medical procedures cannot be high. Where there is doubt, people are not recalled and screened. Potential nosocomial cases (ones that occurred in healthcare settings) are not investigated. There is overwhelming evidence that heterosexual behaviour in African countries does not explain high levels of HIV, but because they are African countries, it is accepted that they have lots of sex, that they should stop doing so and when they do, everything will be ok.

Health facilities in African countries lack adequate drug supplies, have chronic shortages of trained personnel and do not even have enough condoms at a time when they are faced with rising HIV prevalence. It is not credible that, at the same time, there is a very low risk of HIV infection through unsafe medical practices. Global HIV policy is obsessed with sexual HIV transmission to the extent that non-sexual transmission is being completely ignored, especially in developing countries. Informing people of the non-sexual risks of HIV transmission, and how to avoid them, is just as important as informing them of the sexual risks. People have a right to the information they need to protect themselves.

Test All, Treat All for HIV: Just Another Shot in the Dark

The authors of an article entitled ‘HIV drugs for treatment, and for prevention’ write as if to ask why we would delay using antiretroviral (ARV) drugs for preventing, in addition to for treating HIV, when so much evidence points to the effectiveness of such a strategy. But their rhetoric could be interpreted another way. They and others in the HIV industry seem to be saying, in a tone of mounting desperation, “Look, nothing else has worked so far, let’s try it until something else comes along”. In a list of failed possibilities including condoms, behaviour change of various kinds, circumcision, vaccines, microbicides and treating other sexually transmitted infections (STI), something else probably will come along. Whether that something will also fail remains to be seen.

The authors may object that some of those possibilities have not failed, for example, circumcision. Well, results of circumcision trials and even large scale circumcision rollout are shrouded in controversy but in Kenya, the only place where substantial numbers have been circumcised, the issue is far from resolved. And the biggest worry for some people is that Kenya does not have adequate health facilities to rollout any widespread programme safely. Aside from that, some worry that the program is being rolled out before its effectiveness has been adequately demonstrated. Maybe circumcision can help in areas where levels are currently low but this is by no means clear.

The effectiveness of condoms, also, is not as clear as one might expect. The latest results from the Kenya Demographic and Health Survey, 2008-09, suggests that people using condoms are often more likely to be HIV positive. It’s not certain why this is so and people would be unwise to give up using condoms, but a major problem with condoms and contraception in general in some countries, Uganda, for example, is availability and accessibility. The Kenyan DHS report, along with many other DHS reports, also cast doubt on the value of various behaviour change campaigns. Behaviour often doesn’t change, for various reasons. But even where it does, this doesn’t seem to have much impact on HIV transmission.

Testing everyone for HIV and treating everyone found to be HIV positive, the strategy advocated by the authors in question, may well have its virtues. If it’s possible to test everyone in every country that has high HIV prevalence regularly, perhaps every year, that would be a good start. Then, being able to treat all of them, for the rest of their lives, would also be required. Mathematical models have shown, apparently, that if such massive numbers of people could be tested regularly and then treated for the rest of their lives this would, under optimal conditions, quickly eradicate HIV (although not all models are in agreement). All we have to do is ensure optimal conditions.

Uganda doesn’t currently have optimal conditions for such a strategy, nor does any other high prevalence country. Testing is slow, many have never been tested, others return for testing more than once but most don’t. There is even an unmet demand for testing which may take some time to meet, given the country’s poor infrastructure and health network. Condom distribution is failed by a stop-start supply and contraception more generally suffers from similar problems, despite family planning being pursued in the country for several decades before HIV was recognised.

In fact, the country’s reasonably modest aim, to treat all HIV positive people who have reached a specific stage of disease progression, is not being met either. Drugs often don’t reach their destination or arive too late. Some remain in storage, even until they have expired, because of lack of infrastructure and health systems. Funding for ARV treatment comes exclusively from external donors. And these donors are talking about reducing funding substantially, some have already done so. An important question is not just about whether these conditions will be changed but would it really be possible to successfully implement a strategy like ‘test and treat’? Does the country’s performance over the past 25 years suggest that it would be possible?

The results of trials that show that HIV transmission is very low when people are on ARV treatment seem impressive. But a universal ‘test and treat’ programme would be, presumably, rolled out under the same conditions as previous HIV prevention programmes. Or maybe the latest one will be rolled out under optimal conditions? Maybe health institutions, infrastructures, education and other social services will be improved to the extent that this test and treat programme will work. It seems likely that HIV transmission would reduce somewhat without a test and treat programme under these conditions. At least it would be a possibility, however surplus to requirements it may become.

But there is still the same worry about this and all the failed or failing programmes that went before: shouldn’t we be frank about what we know and don’t know about HIV transmission, especially the extent to which HIV is sexually transmitted? We know HIV is not always transmitted sexually, but the HIV industry is very coy about admitting the extent of non-sexual transmission. And all the programmes listed above presuppose sexual transmission of HIV, whether they involve vaccines, microbicides, condoms, behaviour change, circumcision, STI treatment or a selection of these combined. Maybe test and treat is different, perhaps it will also reduce non-sexual HIV transmission. But it won’t, on its own, alter the circumstances that result in non-sexual transmission. Rolling out a disease prevention programme that is indifferent as to how that disease is spread seems foolhardy.