The UK Guardian carries an article arguing that there is a lot of good news for gay people in Africa, that many things are changing for the better. I hope it's true. I hope that, even though several countries are passing legislation that seems to go in the opposite direction, these bills are being rendered obsolete even as they are being discussed.
Of course, what a journalist says one day, despite being repeated my many others the next day, can tend to be rather ephemeral. The very fact that a journalist is discussing something often indicates that it is already old hat. When something as sensitive as gay rights is an issue, some hack with a superficial understanding is the last person you want to be your spokesperson.
I was quite surprised at one of the articles I read about the minister for special programs, Esther Murugi, and her call for greater acceptance of gay people in society. But it was perhaps more surprising that the article was republished by Mars Group Kenya, a human rights organization. The article was so preposterous in its claims and so inept in its arguments that I wondered if Mars Group only posted the article to make the author look like a fool, except that the article was anonymous.
An article in The Standard attempted to use argument rather than bluster. The fact that the argument was patently fallacious means that even people who were convinced by the conclusion, that homosexuality is wrong, may see that the means used to reach the conclusion was highly suspect, at best. I don't believe the author wished to defend homosexuality by raising easily defeated arguments against it; just that those arguments have the load bearing capacity of a wet paper bag.
And a third argument, in The Nation, simply called for a bit of calm and common sense, a bit of compassion, even. Perhaps the author found it difficult to raise arguments against the homophobic outbursts because there was nothing to argue against. I don't have a link to the article but the author, Makau Mutua, makes many interesting points on the subject in another article, including a refutation of the sort of arguments that appear in the Mars Groups article mentioned above.
There's no doubt that Minister Murugi has sparked off a lot of discussion. It's just hard to see where that discussion is going to lead. She hasn't resigned, nor has she been sacked, despite the reactions from some groups, especially religious groups.
On balance, I think good could come from these open discussions, especially where they are genuine exchanges of views rather than the political equivalent of schoolyard rows. But I don't know if it's always safe to discuss sexuality, in particular homosexuality, anywhere and everywhere. I think one still needs to be careful. Ordinary people don't have the levels of protection that politicians and even journalists often enjoy. But I also think arguments can have little impact and I follow Mutua by calling for people to be humane.
Monday, October 11, 2010
Saturday, October 9, 2010
Meaningless HIV Hypotheses Result in Meaningless Predictions
The Lancet has published a report on the "aids2031 project" which "modelled long-term funding needs for HIV/AIDS in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors." The world's press has dutifully repeated choice bits of the report without comment, question or (God forbid!) criticism.
Indeed, the report has the usual veneer of confidence that you find with long term predictions, lots of big figures, a range of scenarios, a typology of country epidemics and some pretty diagrams. If this was about bailing out a handful of rich bankers, the amounts of money would be far higher, the period of time would be shorter and the money would be handed over without much fuss. But as there are tens of millions of people involved and they are mostly living in poor countries, serious questions need to be asked about which spending scenario is 'best'.
The figures are, of course, entirely meaningless. HIV was discovered at a time when it had probably only infected a few million people. It is not known why the virus spread so rapidly in a few countries, all in sub-Saharan Africa, yet it only infected people in very specific risk groups in other countries. In many countries, transmission of the virus peaked around about ten or 15 years after it arrived and then declined. Therefore, in some countries the virus may well be peaking now, in some countries transmission rates continue to drop and in others it has already dropped to a low level.
But the question of why HIV struck, spread, peaked and declined has never been answered. As a result, the virus appears to have waxed and waned independently of what any country did to reduce its spread, which was in most cases nothing, anyhow. In countries like Kenya, Uganda and Tanzania, prevalence is stuck at between 6 or 8%, suggesting a steady stream of new infections. Many are being treated, but how many and how successfully is anyone's guess. Body counts are good for fundraising but not for reassuring funders that everything that can be done is being done.
The four spending scenarios all assume that a steady stream of new infections may continue in some countries and that transmission rates in higher prevalence countries, such as South Africa, Namibia, Botswana, Swaziland and others, will continue to decline. And this may be true, new infections may decline in every country. If, as is assumed by the HIV orthodoxy, HIV is mostly transmitted sexually, rates could never go particularly high anyhow. There is a limit to how much sex people can have. The fact that sexual behavior seems to have only a small effect on HIV transmission rates is irrelevant to the orthodox view.
But the authors of the report don't seem to consider the possibility that HIV transmission rates in some, perhaps many countries, could suddenly spike. Of course, there is unlikely to be a spike in sexual activity, especially a level of activity that goes beyond what is humanly possibly. But such a spike must have occurred at some time, if HIV is almost always transmitted sexually (and I'm talking about African countries).
If you don't accept that HIV is almost always transmitted sexually, a spike of non-sexual transmission, perhaps many spikes, are always a possibility. Such spikes, perhaps occurring in health facilities, involving unsafe injections and other procedures, could occur at any time and are the most reasonable explanation for rates of HIV transmission that has never been accounted for by levels of sexual activity that are beyond what humans are capable of.
The problem with the four different scenarios discussed in the report is that they are not based on any real epidemics, instead they are based on a very faulty paradigm. One can easily generate an infinite number of equally meaningless scenarios based on that same paradigm. None of the scenarios deal with improving health systems or health infrastructure, which could reduce transmission considerably.
Poor conditions in health facilities, which can quite easily explain otherwise inexplicable rates of transmission, remain in all high prevalence countries (or ones that once had high prevalence). As long as they remain, planning for the future is a shot in the dark. But as the HIV industry have long been demonstrating, you don't develop a better aim by practicing shooting in the dark. It's only advisable if you don't know what you've hit, or don't much care.
The authors argue that "substantial reductions in incidence (≥50%) will only occur with introduction of a vaccine or curative treatment." I disagree. Substantial reductions in incidence can be achieved by ensuring that nosocomial transmission is eradicated in every country, especially those which have ever had high rates of transmission. As long as health facilities and services remain underdeveloped and inaccessible, further serious outbreaks of nosocomial HIV transmission can not be ruled out. The authors of the report are not even in a position to diagnose what has been happening in the past, let alone make predictions 20 years hence.
(For discussions of Pre-exposure Prophylaxis (PrEP), see my other blog)
Indeed, the report has the usual veneer of confidence that you find with long term predictions, lots of big figures, a range of scenarios, a typology of country epidemics and some pretty diagrams. If this was about bailing out a handful of rich bankers, the amounts of money would be far higher, the period of time would be shorter and the money would be handed over without much fuss. But as there are tens of millions of people involved and they are mostly living in poor countries, serious questions need to be asked about which spending scenario is 'best'.
The figures are, of course, entirely meaningless. HIV was discovered at a time when it had probably only infected a few million people. It is not known why the virus spread so rapidly in a few countries, all in sub-Saharan Africa, yet it only infected people in very specific risk groups in other countries. In many countries, transmission of the virus peaked around about ten or 15 years after it arrived and then declined. Therefore, in some countries the virus may well be peaking now, in some countries transmission rates continue to drop and in others it has already dropped to a low level.
But the question of why HIV struck, spread, peaked and declined has never been answered. As a result, the virus appears to have waxed and waned independently of what any country did to reduce its spread, which was in most cases nothing, anyhow. In countries like Kenya, Uganda and Tanzania, prevalence is stuck at between 6 or 8%, suggesting a steady stream of new infections. Many are being treated, but how many and how successfully is anyone's guess. Body counts are good for fundraising but not for reassuring funders that everything that can be done is being done.
The four spending scenarios all assume that a steady stream of new infections may continue in some countries and that transmission rates in higher prevalence countries, such as South Africa, Namibia, Botswana, Swaziland and others, will continue to decline. And this may be true, new infections may decline in every country. If, as is assumed by the HIV orthodoxy, HIV is mostly transmitted sexually, rates could never go particularly high anyhow. There is a limit to how much sex people can have. The fact that sexual behavior seems to have only a small effect on HIV transmission rates is irrelevant to the orthodox view.
But the authors of the report don't seem to consider the possibility that HIV transmission rates in some, perhaps many countries, could suddenly spike. Of course, there is unlikely to be a spike in sexual activity, especially a level of activity that goes beyond what is humanly possibly. But such a spike must have occurred at some time, if HIV is almost always transmitted sexually (and I'm talking about African countries).
If you don't accept that HIV is almost always transmitted sexually, a spike of non-sexual transmission, perhaps many spikes, are always a possibility. Such spikes, perhaps occurring in health facilities, involving unsafe injections and other procedures, could occur at any time and are the most reasonable explanation for rates of HIV transmission that has never been accounted for by levels of sexual activity that are beyond what humans are capable of.
The problem with the four different scenarios discussed in the report is that they are not based on any real epidemics, instead they are based on a very faulty paradigm. One can easily generate an infinite number of equally meaningless scenarios based on that same paradigm. None of the scenarios deal with improving health systems or health infrastructure, which could reduce transmission considerably.
Poor conditions in health facilities, which can quite easily explain otherwise inexplicable rates of transmission, remain in all high prevalence countries (or ones that once had high prevalence). As long as they remain, planning for the future is a shot in the dark. But as the HIV industry have long been demonstrating, you don't develop a better aim by practicing shooting in the dark. It's only advisable if you don't know what you've hit, or don't much care.
The authors argue that "substantial reductions in incidence (≥50%) will only occur with introduction of a vaccine or curative treatment." I disagree. Substantial reductions in incidence can be achieved by ensuring that nosocomial transmission is eradicated in every country, especially those which have ever had high rates of transmission. As long as health facilities and services remain underdeveloped and inaccessible, further serious outbreaks of nosocomial HIV transmission can not be ruled out. The authors of the report are not even in a position to diagnose what has been happening in the past, let alone make predictions 20 years hence.
(For discussions of Pre-exposure Prophylaxis (PrEP), see my other blog)
Friday, October 8, 2010
A Vote For Minister Murugi is a Vote for Human Rights
There are senior people who still hold powerful positions, despite facing trial in the International Criminal Court; there are some who have stolen money intended for internally displaced persons; others who have stolen food intended for the starving. Education, health and infrastructure funds have gone missing, having passed through the hads of the most powerful leaders in Kenya. Yet calls for the resignation of these powerful individuals are rarely heard.
But one minister calls for greater acceptance of gays by society and religious leaders want her to resign. The part that religious leaders have played in various scandals in Kenya is often quite unclear and it is alarming to hear that when someone in authority advocates greater tolerance, it is religious leaders who protest the loudest. Condemnation precludes the tolerance that they only seem to preach when it suits them.
The word 'promote' is often used in these contexts. In this instance, Minister Murugi is said to be promoting 'un-African' acts. Do people think the minister is recommending that everyone should try having sex with someone of the same gender? If the minister is promoting anything, it is that people accept that there are others who are different from them. And you don't have to be gay to be different. Difference can refer to gender, tribe, religion, politics, wealth and much else.
And there is another message I am hoping Ms Murugi would like to spread and that is the message of thinking independently. Since when have churches and religious leaders adequately represented the interests of ordinary people? Religious leaders are apart from ordinary people, they are often rich, pampered, treated with deference and hold themselves aloof from everyone else. Ordinary people need to get by on their own resources, or what's left after the religious leaders have got their share.
Kenyans pay dearly with their hard earned cash, and in countless other ways, to keep religious leaders comfortable. But these religious leaders are not in those comfortable positions so that they can tell people how to live their lives. They are, from an ethical point of view, on a level with other people. Some may fall far below, some may live admirable lives. But it is not their place to judge, nor to command, only to advise, support and nurture.
This may even be a good time to renegotiate, or at least reconsider, the role that religious leaders play in people's lives and in the running of their country.
Minister Murugi has done what she was elected to do. What would people prefer? That they sack her and replace her with someone else, who will usurp a role of arbiter of good behavior and executioner of punishments for those who fall out of line? It's almost as if Kenyans want leaders who behave as they wish to but expect their electorate always to fall in line and never, never criticize what their leaders may get up to.
The current situation leads to a lot of fear, violence and discrimination. Is that what Kenyans want? There are few leaders in this country who have made any change for the better and, I agree, change for the better is difficult. But Minister Murungi has tried to make a change that might, eventually, make things better for a very significant minority. And in standing up for one minority, a precedent will have been set for other minorities. Causes that once seemed lost may be won, in time.
Every Kenyan should be calling for Minister Murugi to hold firm in her advocacy of greater acceptance of gays in society. People should be telling their religious leaders that they are overstepping their authority. Indeed, they are perverting their authority by failing to uphold tolerance and instead, spreading intolerance and possibly fanning violence and crime. Every Kenyan stands to gain from greater tolerance. Nor need one be gay to benefit from recognition of the legitimacy of difference, whether that difference be sexual, racial, political or anything else.
But one minister calls for greater acceptance of gays by society and religious leaders want her to resign. The part that religious leaders have played in various scandals in Kenya is often quite unclear and it is alarming to hear that when someone in authority advocates greater tolerance, it is religious leaders who protest the loudest. Condemnation precludes the tolerance that they only seem to preach when it suits them.
The word 'promote' is often used in these contexts. In this instance, Minister Murugi is said to be promoting 'un-African' acts. Do people think the minister is recommending that everyone should try having sex with someone of the same gender? If the minister is promoting anything, it is that people accept that there are others who are different from them. And you don't have to be gay to be different. Difference can refer to gender, tribe, religion, politics, wealth and much else.
And there is another message I am hoping Ms Murugi would like to spread and that is the message of thinking independently. Since when have churches and religious leaders adequately represented the interests of ordinary people? Religious leaders are apart from ordinary people, they are often rich, pampered, treated with deference and hold themselves aloof from everyone else. Ordinary people need to get by on their own resources, or what's left after the religious leaders have got their share.
Kenyans pay dearly with their hard earned cash, and in countless other ways, to keep religious leaders comfortable. But these religious leaders are not in those comfortable positions so that they can tell people how to live their lives. They are, from an ethical point of view, on a level with other people. Some may fall far below, some may live admirable lives. But it is not their place to judge, nor to command, only to advise, support and nurture.
This may even be a good time to renegotiate, or at least reconsider, the role that religious leaders play in people's lives and in the running of their country.
Minister Murugi has done what she was elected to do. What would people prefer? That they sack her and replace her with someone else, who will usurp a role of arbiter of good behavior and executioner of punishments for those who fall out of line? It's almost as if Kenyans want leaders who behave as they wish to but expect their electorate always to fall in line and never, never criticize what their leaders may get up to.
The current situation leads to a lot of fear, violence and discrimination. Is that what Kenyans want? There are few leaders in this country who have made any change for the better and, I agree, change for the better is difficult. But Minister Murungi has tried to make a change that might, eventually, make things better for a very significant minority. And in standing up for one minority, a precedent will have been set for other minorities. Causes that once seemed lost may be won, in time.
Every Kenyan should be calling for Minister Murugi to hold firm in her advocacy of greater acceptance of gays in society. People should be telling their religious leaders that they are overstepping their authority. Indeed, they are perverting their authority by failing to uphold tolerance and instead, spreading intolerance and possibly fanning violence and crime. Every Kenyan stands to gain from greater tolerance. Nor need one be gay to benefit from recognition of the legitimacy of difference, whether that difference be sexual, racial, political or anything else.
Wednesday, October 6, 2010
Kenyan Health Care Suffers From Underfunding and Corruption
Following recent remarks by Kenya's Health Services Minister, Professor Anyang' Nyong'o, to the effect that there major problems with health care provision in the country, there have been a couple of other articles on the same subject.
One of them calls for greater investment in the health sector and suggests that problems in the sector are common knowledge. The article is not very specific and doesn't cite the study it purports to be referring to but it mentions inadequate staffing, drug shortages, lack of equipment and paucity of facilities.
The article claims that conditions are worse in rural than in urban areas, which is debatable, but it says that the rural, slumdwelling poor "simply lack access to quality health services". Indeed, I'd say that in some places people lack access to any health services, quality or otherwise. Staff shortages, the article goes on, leads to the use of shortcuts, longer procedures are avoided and quick fixes are widely used.
Apparently corruption is also a problem in the health sector and "Provisions to public health facilities end up in the hands of crooks, who sell them to private hospitals." The article concludes by calling for more investment, but perhaps any finance or resources involved need to be more carefully monitored as well.
Another article deals specifically with corruption and mismanagement in the sector. Both the Medical Services and the Public Health ministrys are mentioned (there are two on account of the power sharing agreement made following the post-election disputes in 2008). This article also mentions shortages of drugs and poor supervision.
According to the article, the report by the Kenya Anti-Corruption Commission "found absenteeism by medical staff, flawed procurement processes, theft of drugs and other medical supplies, and unnecessary referral of patients to private clinics as major forms of corruption." There is also, apparently, a lack of clarity about fees that patients are charged.
Minister Nyong'o specifically draws attention to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. But the health problems that Kenyans face are numerous. In addition to greater awareness about these there should also be far more spending on safe health care that is accessible to everyone.
One of them calls for greater investment in the health sector and suggests that problems in the sector are common knowledge. The article is not very specific and doesn't cite the study it purports to be referring to but it mentions inadequate staffing, drug shortages, lack of equipment and paucity of facilities.
The article claims that conditions are worse in rural than in urban areas, which is debatable, but it says that the rural, slumdwelling poor "simply lack access to quality health services". Indeed, I'd say that in some places people lack access to any health services, quality or otherwise. Staff shortages, the article goes on, leads to the use of shortcuts, longer procedures are avoided and quick fixes are widely used.
Apparently corruption is also a problem in the health sector and "Provisions to public health facilities end up in the hands of crooks, who sell them to private hospitals." The article concludes by calling for more investment, but perhaps any finance or resources involved need to be more carefully monitored as well.
Another article deals specifically with corruption and mismanagement in the sector. Both the Medical Services and the Public Health ministrys are mentioned (there are two on account of the power sharing agreement made following the post-election disputes in 2008). This article also mentions shortages of drugs and poor supervision.
According to the article, the report by the Kenya Anti-Corruption Commission "found absenteeism by medical staff, flawed procurement processes, theft of drugs and other medical supplies, and unnecessary referral of patients to private clinics as major forms of corruption." There is also, apparently, a lack of clarity about fees that patients are charged.
Minister Nyong'o specifically draws attention to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. But the health problems that Kenyans face are numerous. In addition to greater awareness about these there should also be far more spending on safe health care that is accessible to everyone.
Monday, October 4, 2010
Storymoja Hay Festival 2010, Nairobi
The Storymoja Hay Festival 2010, held in Nairobi at the weekend, was billed as an arts festival that would include poetry, literature, debate, discussion and other events.But what I took away from the festival owed a lot to the free copy of 'Living Memories', by Al Kags, that was included in the ticket price.
This was a collection of stories from older Kenyans, what they could remember from earlier times. These stories were disturbing, but also very moving. Some of the memories were from the thirties and forties but most were from the fifties, specifically, the Mau Mau years. I have read about the vicious treatment meted out by the British before, but these stories all added something to knowledge of the period that no amount of academic writing could.
I hope Al Kags and others manage to collect and publish lots more oral accounts, not just of bad times, but also of ordinary times, good times and things that have been forgotten by some and were never known by others. Occasionally I hear stories myself, but there is no substitute for oral histories being collected while it's still possible.
Sadly, there were not that many visitors on Saturday, the only day I was there. But I wouldn't be surprised if people were put off by the 500 shilling ticket price. This is not the way to make arts and literature more accessible.
This high cost is quite a contrast with the Maker Faire exhibition that took place at the end of August. This had no entry fee and was very well attended, despite coinciding with the promulgation of the new Constitution.
For people interested in poetry reading, storytelling, debate and discussion, there were certainly opportunities at the Storymoja Festival. And perhaps it seems negative to ignore these and complain about the cost.
But the lack of interest in literature and reading in Kenya, as well as arts in general, is disappointing. Children are brought up seeing reading as a chore, never as a form of entertainment. Even if it can't compete with TV and the rest, it should appear somewhere on the list.
However, there is one particular factor which ensures that most children will not be exposed to much literature in the near future, and that is the costs involved. The few bookshops in most cities sell a small range of books at exorbitant prices, most of them being published abroad. The choice for children is even more limited than that for adults. At the festival, much of what was on offer could as easily be bought in a Nairobi bookshop.
There was clearly plenty of sponsorship for the festival. I spoke to some people who had been involved in the lead-up to the event and a lot of things took place that might not have been obvious to visitors. The free book of living memories is just the sort of thing that should have been subsidized, rather than expensive VIP entertainment. But that book is a great example of how much more could be done.
If money is availabe for such events, perhaps some of it could be spent making literature and the arts in general more accessible to people, and more relevant. Most books were being sold at European prices, even many of the books by African authors. And the locally published books, at several hundred shillings, are still too expensive for most Kenyan people.
For those who went to the festival, what can they take away? If they have developed a desire to hear more poetry or stories, where will they go next? Other events are similarly priced and usually held in expensive Nairobi venues. How many people were, as a result of attending the festival, signed up for a mailing list so they can be kept informed of such events and anything else related to literature and the arts?
There was another exception to the high cost of most of the items that people could buy. An educational publisher, the name of which I don't remember, was selling indigenously produced comics. They were comic versions of folk tales, very simple, but very beautiful. It may be because they were published in the 1980s that they were only priced 5 shillings. But even 25 shillings or more might have attracted a lot of buyers. The series is called 'Pichadithi' (from 'picture' and the Swahili for story, hadithi).
My views of the festival are somewhat mixed. I can see clearly, just as I could after the Maker Faire, that there is a lot on offer in Kenya, but that there could be a great deal more. Similar to the inventions and creative items being exhibited at the Maker Faire, there are incipient stories, poems, novels, plays and much more. But a lot of work needs to be done to allow them to become real and more still to make literature and the arts accessible to everyone.
This was a collection of stories from older Kenyans, what they could remember from earlier times. These stories were disturbing, but also very moving. Some of the memories were from the thirties and forties but most were from the fifties, specifically, the Mau Mau years. I have read about the vicious treatment meted out by the British before, but these stories all added something to knowledge of the period that no amount of academic writing could.
I hope Al Kags and others manage to collect and publish lots more oral accounts, not just of bad times, but also of ordinary times, good times and things that have been forgotten by some and were never known by others. Occasionally I hear stories myself, but there is no substitute for oral histories being collected while it's still possible.
Sadly, there were not that many visitors on Saturday, the only day I was there. But I wouldn't be surprised if people were put off by the 500 shilling ticket price. This is not the way to make arts and literature more accessible.
This high cost is quite a contrast with the Maker Faire exhibition that took place at the end of August. This had no entry fee and was very well attended, despite coinciding with the promulgation of the new Constitution.
For people interested in poetry reading, storytelling, debate and discussion, there were certainly opportunities at the Storymoja Festival. And perhaps it seems negative to ignore these and complain about the cost.
But the lack of interest in literature and reading in Kenya, as well as arts in general, is disappointing. Children are brought up seeing reading as a chore, never as a form of entertainment. Even if it can't compete with TV and the rest, it should appear somewhere on the list.
However, there is one particular factor which ensures that most children will not be exposed to much literature in the near future, and that is the costs involved. The few bookshops in most cities sell a small range of books at exorbitant prices, most of them being published abroad. The choice for children is even more limited than that for adults. At the festival, much of what was on offer could as easily be bought in a Nairobi bookshop.
There was clearly plenty of sponsorship for the festival. I spoke to some people who had been involved in the lead-up to the event and a lot of things took place that might not have been obvious to visitors. The free book of living memories is just the sort of thing that should have been subsidized, rather than expensive VIP entertainment. But that book is a great example of how much more could be done.
If money is availabe for such events, perhaps some of it could be spent making literature and the arts in general more accessible to people, and more relevant. Most books were being sold at European prices, even many of the books by African authors. And the locally published books, at several hundred shillings, are still too expensive for most Kenyan people.
For those who went to the festival, what can they take away? If they have developed a desire to hear more poetry or stories, where will they go next? Other events are similarly priced and usually held in expensive Nairobi venues. How many people were, as a result of attending the festival, signed up for a mailing list so they can be kept informed of such events and anything else related to literature and the arts?
There was another exception to the high cost of most of the items that people could buy. An educational publisher, the name of which I don't remember, was selling indigenously produced comics. They were comic versions of folk tales, very simple, but very beautiful. It may be because they were published in the 1980s that they were only priced 5 shillings. But even 25 shillings or more might have attracted a lot of buyers. The series is called 'Pichadithi' (from 'picture' and the Swahili for story, hadithi).
My views of the festival are somewhat mixed. I can see clearly, just as I could after the Maker Faire, that there is a lot on offer in Kenya, but that there could be a great deal more. Similar to the inventions and creative items being exhibited at the Maker Faire, there are incipient stories, poems, novels, plays and much more. But a lot of work needs to be done to allow them to become real and more still to make literature and the arts accessible to everyone.
Sunday, October 3, 2010
Testing the HIV 'Test and Treat' Strategy
A 'Test and Treat' strategy, also referred to as 'Treatment as (or 'is') Prevention', has not shown very good results in a study in China. Such strategies were the most hyped item on the agenda just under two years ago in the HIV/AIDS world. The claim was that HIV positive people responding to treatment usually have a very low viral load so they are far less likely to transmit the virus to their sexual partners; therefore everyone in a population could be tested regularly, perhaps every year, and immediately put on antiretroviral (ARV) treatment if found to be positive.
The study in China looked at discordant couples, couples where only one partner is HIV positive. HIV transmission rates were relatively low, at 4.3% over a three year period (a seroconversation rate of 1.7 per 100 person years), though the rate increased over time.
Risk was higher where sexual activity was higher and where condoms were not always used. Risk was also higher among those who had lower scores in a psychological test. But the ARV treatment itself did not lower the risk of transmission.
Another piece of research could lend some corroboration to the Chinese research. Though not looking at Test and Treat specifically, it does suggests that such strategies may not be very effective outside of the very closely monitored trial conditions that applied to earlier randomized controlled trials.
This piece of research investigated the effects of $6 billion of PEPFAR funding (President's Emergency Plan For Aids Relief) on AIDS related deaths and prevalence in recipient countries. While the fund may have had some success in lowering death rates from AIDS, it did not significantly lower prevalence over its first four years in operation. The authors and speculate that four years may be too short a period.
It is estimated that death rates were reduced by 10.5% (an estimated 1.2 million deaths). However, the number of people put on treatment could be as much as 100 times higher than in the Chinese research. If mass treatment had much effect on transmission, one would expect some detectable effect on prevalence, even after just four years.
But unless you believe the UNAIDS orthodoxy about HIV being mainly transmitted sexually in African countries, the low rates of sexual transmission found in the Chinese research will not be very surprising. The area where the research took place, Zhumadian, has higher than average HIV prevalence because of the use of infected blood products from paid plasma donors in the 1990s.
Perhaps the investigators in the PEPFAR research should not have been so surprised that the $1.2 billion allocated to prevention, about one fifth of the total, had little impact. Because most PEPFAR prevention 'strategies' assume the truth of the UNAIDS orthodoxy, that most HIV transmission in African countries is sexual. Maybe they will now start to see that the orthodoxy needs to be challenged.
In addition to casting doubt on the completely untenable and highly racist assumptions that make up the orthodox view of HIV transmission in African countries, the above research could also question the medicalization of HIV and other diseases. This is the implicit assumption that health is just a matter of treating diseases with drugs, as opposed to ensuring that the conditions under which diseases spread are dealt with.
If high rates of non-sexual HIV transmission can occur in China, they can occur in African countries. And if low rates of sexual transmission can occur in China, they may also be occurring in Africa. Low rates of sexual transmission may be the norm in Africa and it is late in the day to start investigating the contribution that non-sexual transmission plays. But we have a duty to investigate this if we want to have any impact on African epidemics. We can no longer allow prejudices to determine what should and should not be asked about the massive rates of HIV transmission found in a handful of countries in Africa.
The study in China looked at discordant couples, couples where only one partner is HIV positive. HIV transmission rates were relatively low, at 4.3% over a three year period (a seroconversation rate of 1.7 per 100 person years), though the rate increased over time.
Risk was higher where sexual activity was higher and where condoms were not always used. Risk was also higher among those who had lower scores in a psychological test. But the ARV treatment itself did not lower the risk of transmission.
Another piece of research could lend some corroboration to the Chinese research. Though not looking at Test and Treat specifically, it does suggests that such strategies may not be very effective outside of the very closely monitored trial conditions that applied to earlier randomized controlled trials.
This piece of research investigated the effects of $6 billion of PEPFAR funding (President's Emergency Plan For Aids Relief) on AIDS related deaths and prevalence in recipient countries. While the fund may have had some success in lowering death rates from AIDS, it did not significantly lower prevalence over its first four years in operation. The authors and speculate that four years may be too short a period.
It is estimated that death rates were reduced by 10.5% (an estimated 1.2 million deaths). However, the number of people put on treatment could be as much as 100 times higher than in the Chinese research. If mass treatment had much effect on transmission, one would expect some detectable effect on prevalence, even after just four years.
But unless you believe the UNAIDS orthodoxy about HIV being mainly transmitted sexually in African countries, the low rates of sexual transmission found in the Chinese research will not be very surprising. The area where the research took place, Zhumadian, has higher than average HIV prevalence because of the use of infected blood products from paid plasma donors in the 1990s.
Perhaps the investigators in the PEPFAR research should not have been so surprised that the $1.2 billion allocated to prevention, about one fifth of the total, had little impact. Because most PEPFAR prevention 'strategies' assume the truth of the UNAIDS orthodoxy, that most HIV transmission in African countries is sexual. Maybe they will now start to see that the orthodoxy needs to be challenged.
In addition to casting doubt on the completely untenable and highly racist assumptions that make up the orthodox view of HIV transmission in African countries, the above research could also question the medicalization of HIV and other diseases. This is the implicit assumption that health is just a matter of treating diseases with drugs, as opposed to ensuring that the conditions under which diseases spread are dealt with.
If high rates of non-sexual HIV transmission can occur in China, they can occur in African countries. And if low rates of sexual transmission can occur in China, they may also be occurring in Africa. Low rates of sexual transmission may be the norm in Africa and it is late in the day to start investigating the contribution that non-sexual transmission plays. But we have a duty to investigate this if we want to have any impact on African epidemics. We can no longer allow prejudices to determine what should and should not be asked about the massive rates of HIV transmission found in a handful of countries in Africa.
Friday, October 1, 2010
Nosocomial and Iatrogenic HIV Transmission in Kenya
I have mentioned non-sexual HIV transmission, and especially transmission through unsafe health care, on a number of occasions. However, some people have interpreted such phenomena in very different ways. Though I have never claimed it, some people seem to think that I am saying that most HIV transmission in Africans countries is non-sexual. I am not claiming this, only that a lot of HIV transmission could be non-sexual and a lot of the 'evidence' for sexual transmission is being manipulated, even though it points to something other than sexual behavior as being behind very high rates of transmission.
Nor am I claiming that every person who visits a health facility is at the same risk of being infected. Even in countries with very high prevalence of HIV and other blood-borne viruses, this doesn't mean that HIV transmission in health facilities is common. Safety and hygiene may be a priority most of the time. Even if the odd procedure is missed now and again, this doesn't mean someone is likely to be infected through a medical procedure. For a start, equipment used needs to be contaminated. And even then, the probability of being infected might only be a few percent.
Most health professionals may follow guidelines religiously. The worry is when there is a shortage of equipment, a lack of clarity about roles or procedures, a temporary drop in vigilance. The fact that such events don't often occur might make them even less likely to be spotted in time. But even when such things go wrong, they still might not give rise to a high risk of people being infected with HIV or anything else. It depends on many circumstances.
I argued recently that sexual transmission of HIV, being quite inefficient, cannot give rise to infections quickly enough or in high enough numbers to explain very serious HIV epidemics like those found in many Southern African countries, or even those found in East Africa and other countries with medium epidemics. I used the terms 'Mediocristan' and 'Extremistan' from Nassim Nicholas Taleb's book The Black Swan and suggested that sexual transmission of HIV is a phenomenon of Mediocristan but that transmission in health facilities is from the realm of Extremistan.
In other words, medical transmission of HIV may not happen all the time, it may not even happen very much. But when it happens, it can affect large numbers of people. Some events may not affect many people, they may just peter out without anyone noticing. Perhaps a few infections will be found, of HIV, hepatitis or something else. But they may never be identified as medically transmitted. This sort of event is still one of Mediocristan. But if the conditions are right and some unsafe procedure results in HIV being transmitted, the number infected could be very high. Inordinately high rates of transmission are possible in health settings that are not possible through unsafe sexual behavior, no matter how much of it may take place.
There have been quite a number of documented (though mainly uninvestigated) outbreaks of HIV that have taken place in medical facilities. These have taken place in both rich and poor countries. The only difference is that in rich countries it is possible to recall and attend to tens of thousands of people. And the risk of infection is not too high if HIV and prevalence of other blood-borne diseases is low in the population. But in poor countries, even if the possibility of an outbreak is noticed, it is unlikely that their health services will have the capacity to investigate, let alone identify all those infected.
So, I am not saying that most HIV infections in Kenya, for example, come from some kind of medical treatment, possibly unsafe injections. I'm saying that in a medium prevalence epidemic, such as Kenya's, some non-sexual transmission must have occurred, especially in areas like Nyanza. There, prevalence is exceptionally high among members of the Luo tribe. Also Western province, where prevalence is exceptionally high among Luhya women. There are probably still plenty of medical transmission events occurring and, if not, there probably will be some in the future.
In countries with the highest HIV transmission rates, such as Swaziland, Zimbabwe, Namibia, Botswana, South Africa and others, medical transmission is likely to contribute a far bigger proportion of infections than in lower prevalence countries. Access to health services is also quite high in these countries. But some of the lower prevalence countries, such as those in East Africa, have lower levels of health services, accessible to far fewer people. And there are many low prevalence areas that also have low access to health services and high prevalence areas with high access to health services. So this connection, if it really is a connection, needs to be investigated.
There are other non-sexual risks relating to HIV transmission, such as through cosmetic practices, head, face and body shaving, manicure, pedicure, tattooing and others. These probably happen, but the question of how often is an empirical one. In countries where most people don't attend medical facilities very much, an epidemic could bump along at a relatively low prevalence for years, much as it has done in Kenya, Uganda, Tanzania and various other countries, with all modes of transmission contributing a steady proportion.
An increase in medically transmitted infections could have quite a profound impact on prevalence, but there's no reason why such an outbreak should be noticed. Or rather, the effects of the outbreak might only be noticed little by little and might not seem like an event with a single, identifiable cause. Especially if no one is looking for the cause or they assume there was a sudden spike in 'unsafe' sexual activity, the extent of which surpasses credibility, if anyone was worried about what is and is not credible about African sexuality.
This is why I have drawn attention to the comments of the Kenyan Medical Services Minister, Professor Anyang' Nyong'o. He has alluded to the state of Kenya's health services, shortages of personnel, overuse of injections, unsafe practices and the consequent risks of nosocomial transmission of HIV, hepatitis and other blood-borne diseases. Now that the country is aware of this risk, it's time to take steps to improve safety in health facilities and rethink the approach to HIV that limits itself to lecturing people about what they should and shouldn't do in their private lives. People need to be aware of the serious non-sexual risks that exist and they should be made aware of how to avoid such risks.
The yearly rate of new HIV transmissions in Kenya may presently be low. Sexual transmission, I would argue, is always low; cosmetic and other practices may also contribute very little. But in a country with health service provision as poor as Kenya's, it's only a matter of time before a significant outbreak occurs. Some significant outbreaks may have already occurred, surveillance is far to low to detect such an event. Unless UNAIDS and others with control of finance and policy are prepared to, like Minister Nyong'o, accept that nosocomial transmission takes place, has always taken place, and will continue to take place, HIV epidemics in African countries will never be reduced, let alone eradicated.
Nor am I claiming that every person who visits a health facility is at the same risk of being infected. Even in countries with very high prevalence of HIV and other blood-borne viruses, this doesn't mean that HIV transmission in health facilities is common. Safety and hygiene may be a priority most of the time. Even if the odd procedure is missed now and again, this doesn't mean someone is likely to be infected through a medical procedure. For a start, equipment used needs to be contaminated. And even then, the probability of being infected might only be a few percent.
Most health professionals may follow guidelines religiously. The worry is when there is a shortage of equipment, a lack of clarity about roles or procedures, a temporary drop in vigilance. The fact that such events don't often occur might make them even less likely to be spotted in time. But even when such things go wrong, they still might not give rise to a high risk of people being infected with HIV or anything else. It depends on many circumstances.
I argued recently that sexual transmission of HIV, being quite inefficient, cannot give rise to infections quickly enough or in high enough numbers to explain very serious HIV epidemics like those found in many Southern African countries, or even those found in East Africa and other countries with medium epidemics. I used the terms 'Mediocristan' and 'Extremistan' from Nassim Nicholas Taleb's book The Black Swan and suggested that sexual transmission of HIV is a phenomenon of Mediocristan but that transmission in health facilities is from the realm of Extremistan.
In other words, medical transmission of HIV may not happen all the time, it may not even happen very much. But when it happens, it can affect large numbers of people. Some events may not affect many people, they may just peter out without anyone noticing. Perhaps a few infections will be found, of HIV, hepatitis or something else. But they may never be identified as medically transmitted. This sort of event is still one of Mediocristan. But if the conditions are right and some unsafe procedure results in HIV being transmitted, the number infected could be very high. Inordinately high rates of transmission are possible in health settings that are not possible through unsafe sexual behavior, no matter how much of it may take place.
There have been quite a number of documented (though mainly uninvestigated) outbreaks of HIV that have taken place in medical facilities. These have taken place in both rich and poor countries. The only difference is that in rich countries it is possible to recall and attend to tens of thousands of people. And the risk of infection is not too high if HIV and prevalence of other blood-borne diseases is low in the population. But in poor countries, even if the possibility of an outbreak is noticed, it is unlikely that their health services will have the capacity to investigate, let alone identify all those infected.
So, I am not saying that most HIV infections in Kenya, for example, come from some kind of medical treatment, possibly unsafe injections. I'm saying that in a medium prevalence epidemic, such as Kenya's, some non-sexual transmission must have occurred, especially in areas like Nyanza. There, prevalence is exceptionally high among members of the Luo tribe. Also Western province, where prevalence is exceptionally high among Luhya women. There are probably still plenty of medical transmission events occurring and, if not, there probably will be some in the future.
In countries with the highest HIV transmission rates, such as Swaziland, Zimbabwe, Namibia, Botswana, South Africa and others, medical transmission is likely to contribute a far bigger proportion of infections than in lower prevalence countries. Access to health services is also quite high in these countries. But some of the lower prevalence countries, such as those in East Africa, have lower levels of health services, accessible to far fewer people. And there are many low prevalence areas that also have low access to health services and high prevalence areas with high access to health services. So this connection, if it really is a connection, needs to be investigated.
There are other non-sexual risks relating to HIV transmission, such as through cosmetic practices, head, face and body shaving, manicure, pedicure, tattooing and others. These probably happen, but the question of how often is an empirical one. In countries where most people don't attend medical facilities very much, an epidemic could bump along at a relatively low prevalence for years, much as it has done in Kenya, Uganda, Tanzania and various other countries, with all modes of transmission contributing a steady proportion.
An increase in medically transmitted infections could have quite a profound impact on prevalence, but there's no reason why such an outbreak should be noticed. Or rather, the effects of the outbreak might only be noticed little by little and might not seem like an event with a single, identifiable cause. Especially if no one is looking for the cause or they assume there was a sudden spike in 'unsafe' sexual activity, the extent of which surpasses credibility, if anyone was worried about what is and is not credible about African sexuality.
This is why I have drawn attention to the comments of the Kenyan Medical Services Minister, Professor Anyang' Nyong'o. He has alluded to the state of Kenya's health services, shortages of personnel, overuse of injections, unsafe practices and the consequent risks of nosocomial transmission of HIV, hepatitis and other blood-borne diseases. Now that the country is aware of this risk, it's time to take steps to improve safety in health facilities and rethink the approach to HIV that limits itself to lecturing people about what they should and shouldn't do in their private lives. People need to be aware of the serious non-sexual risks that exist and they should be made aware of how to avoid such risks.
The yearly rate of new HIV transmissions in Kenya may presently be low. Sexual transmission, I would argue, is always low; cosmetic and other practices may also contribute very little. But in a country with health service provision as poor as Kenya's, it's only a matter of time before a significant outbreak occurs. Some significant outbreaks may have already occurred, surveillance is far to low to detect such an event. Unless UNAIDS and others with control of finance and policy are prepared to, like Minister Nyong'o, accept that nosocomial transmission takes place, has always taken place, and will continue to take place, HIV epidemics in African countries will never be reduced, let alone eradicated.
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