Blinded by Influence: the 'Rightness' of Big Funding

Matthew Black has raised some issues in response to my last post, which I would like to answer in detail. It appears that his opinion is based to some extent on a very brief article which denies, but doesn't adequately refute, some of the most pressing arguments against the behavioral paradigm, the view that HIV is almost always transmitted sexually in African countries.

Firstly, in saying that I don't believe all HIV is transmitted sexually, I am not claiming that it is never transmitted sexually. Nor am I saying that it is mostly transmitted non-sexually, by unsafe health care or any other non-sexual modes.

What I am saying is that we do not know the extent of non-sexual transmission and that it is vital to address this lack of knowledge in order to judge how much time, effort and resources are spent on each mode of transmission.

Aside from lack of thorough research into non-sexual transmission, particularly through unsafe injections, but by no means limited to that, no adequate explanation has ever been given as to why heterosexual transmision of HIV is realatively uncommon outside of a few high prevalence countries, mostly in sub-Saharan Africa.

People all over the world have sex, some of them have a lot of sex and it is often 'unsafe'. But rates of sexual transmission appear to be hundreds of times higher in a few African countries, if UNAIDS and the AIDS orthodoxy are to be believed.

Another anomaly is what is known about non-sexual HIV transmission: not only is it far more efficient than heterosexual transmission (regardless of which sets of figures you actually use) but it is also the commonest form of transmission in most Western countries and other countries where prevalence is not excessively high.

Indeed, aside from men who have sex with men, the only high prevalence group in Western countries is intravenous drug users. Even sex workers who are not intravenous drug users are very unlikely to be infected with HIV.

The Service Provision Assessment data I refer to in my previous posting is the latest available from Measure DHS and this kind of survey only takes place about every five years, the same as most demographic and health data relating to HIV (an assessment was carried out last year but the data is not yet publicly available).

But health services are not receiving anything like the sort of resources that are being thrown at antiretroviral drugs. If anything, as populations increase, services are less and less able to cope with demand.

But we don't need to ask if health facilities in high HIV prevalence countries are risky places for those who wish to avoid HIV, hepatitis and other blood borne viruses. The UN itself bears witnes to the fact that they are not trustworthy. The UN warns its own personnel to avoid health facilities that are not approved by the UN itself because of the known risks.

But when it comes to advising African countries about HIV risks, the UN changes its story and says that HIV is unlikely to be transmitted non-sexually, particularly through unsafe injections. Why there is this discrepancy in their advice, we are not told.

But despite the WHO claims in the brief Continuing Medical Education Journal document mentioned above, the WHO has also published material which accepts that 70% of injections globally are unsafe and an unknown percentage, perhaps as high as 15 or 20%, may be contaminated with HIV. Huge percentages of hepatitis B and C are transmitted by unsafe injections. And the WHO is part of the UN.

Mr Black may be interested to know what happens in Western countries when there has been a suspected case of unsterile equipment being used on patients in health facilities. Hundreds, thousands, even tens of thousands of people are contacted and advised to be tested for HIV and other viruses. I cite just one example here, but new ones are reported every month. But I have cited others in the past.

On many occasions in rich countries, nosocomial transmissions have been identified and treated, where possible. Such investigations do not take place in countries that have very poor health facilities, and that's what I and Gisselquist, Brody, Potterat and a number of other people are questioning.

People in Western countries do not tolerate such outbreaks occurring. When they do occur an investigation follows. As a result of the investigation, procedures are improved accordingly. Why are the authors of this CMEJ article prepared to tolerate conditions in African countries, where health facilities are so lacking in every way, that would be unthinkable in Western countries?

And more importantly, how can UNAIDS and others deny that non-sexual HIV transmission is worth investigating in countries where they have not even bothered to investigate it?

The issue, Mr Black, is not just about whether sexual transmission is or isn't responsible for most HIV infections in a handful of high prevalence countries: the issue is that the contribution of non-sexual transmission, especially through unsafe healthcare, has never been properly evaluated in those countries. And just as UNAIDS seem afraid to use African health facilities themselves, they also seem afraid to investigate them.

Public Money Pays the Piper, So Why Do Big Pharma Call the Tune?

Every now and again I read UNAIDS' publications. Not just for the pretty pictures and diagrams, but because I hope that some day they will play a different tune. Mainly, I want to hear that they have modified their claim that 90% of HIV is transmitted through heterosexual sex. That was the figure that appeared in a draft of their 'Getting to Zero' 2011-2015 Strategic plan. In the published version, the figure is 80%.

But that's not really a modification. They just got it wrong. The official line has for a long time been that 80% of transmission is from heterosexual sex and almost 20% is through mother to child transmission (MTCT). Men having sex with men and intravenous drug users, it appears, make a negligible contribution to high prevalence epidemics. In fact, most HIV transmission is said to result from what is essentially low risk sexual behavior. Which is strange, for a virus that is difficult to transmit through penile-vaginal sex.

UNAIDS' claim to use a 'Know your Epidemic, Know your Response' methodology is flatly contradicted by their claims about heterosexual and other modes of transmission. They don't know their epidemics and nor, we can safely conclude, do they know their response. That's why they have failed to have much impact on transmission rates.

Oddly enough, the plan doesn't mention abstinence, ABC or any of the other rubbish that has filled so much of the official literature. In fact, prevention by useless strategies appears to have been replaced with prevention by wishful thinking. Instead of admitting that hardly anything has been spent effectively on prevention since UNAIDS was established, they are implying that treating people is preventing HIV transmission.

In truth, antiretroviral treatment can reduce transmission, but on its own it is unlikely to reduce it very much. Indeed, many of the figures that 'support' various claims made by UNAIDS about heterosexual transmission are years out of date and are assumed or modeled figures, they are not drawn from empirical research. Therefore, UNAIDS also undermines its many claims that their strategic plan is 'evidence-based' or 'evidence informed'.

One area of HIV transmission that presumably fits into the 2% category is non-sexual transmission, through unsafe healthcare, unsafe cosmetic practices, etc. The WHO, in the last year or so, has admitted that an estimated 40% of injections in African countries are unsafe and the organization accepts that at least 5% of HIV infections could come from such unsafe injections. This estimate is for a region, not for any particular country. The figure for some countries is likely to be a lot higher.

Despite claiming that HIV transmission from unsafe injections is very low, UNAIDS warns its employees and those of the UN as a whole to avoid medical facilities that are not UN approved, as I mentioned yesterday (and on other occasions). If there is a risk for UN employees, there is a risk for non-UN employees. So why the discrepancy between the WHO's figures and those of UNAIDS, and why the warning for UN employees but not for ordinary people?


The whole Strategic Plan is similarly biased towards a behavioral view of HIV, whereby it is depicted as overwhelmingly a matter of individual sexual behavior. This is a dated view, it hasn't worked in the past and it is not going to work in the future. It is difficult to see how this Strategic Plan differs materially from anything UNAIDS has published in the past. Most of the references seem to be to UNAIDS publications or similar.

Finally (although there is little positive that one could say about the Plan), it states that "investment in HIV is critical for the strengthening of health systems and achievement of the MDGs." On the contrary, investment in health systems is critical for the treatment and prevention of HIV. Claiming that money spent on HIV is money spent on health systems is neither honest nor based on empirical evidence.

One only need take a cursory look at Kenya's Service Provision Assessment (or the SPA for any other high prevalence country) to see how unprepared they are to play any part in preventing HIV transmission, especially nosocomially transmitted HIV. And they are equally unprepared to treat or care for HIV positive people adequately.

UNAIDS need to pay a little less attention to what politicians, religious leaders and industrialists think they should do and pay a bit more attention to HIV, a blood-borne virus that is sometimes transmitted sexually, especially through anal sex. They have sold enough drugs for the friends in the pharmaceutical industry and it's time to address the one disease they were established to eradicate.

Comfortable With High Rates of Mother to Child HIV Transmission?

According to the UN, "Extra precautions should be taken...when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." This excellent advice is given to UN employees. But it is not given to people who don't have the benefit of access to 'UN approved' medical facilities.

Is everyone comfortable with this? UNAIDS say that only around 2.5% of HIV transmission results from unsafe medical practices in high prevalence countries. But they think it necessary to warn UN personnel working in high prevalence countries to avoid the health facilities that people in developing countries have to put up with, if they actually have access to health facilities at all.

Sometimes you read about how awful it is that large numbers of infants are still born HIV positive or go on to be infected by their mother (mother to child transmission or MTCT). And it is horrific, but it is preventable. The problem with worrying mainly about the infants is that they are infected by someone else who is already infected, possibly their mother. And their mother's infection was probably also preventable.

So why does UNAIDS not worry about the person who infects the infant? And why is the person who infects the infant possibly their mother? I can't answer the first question but I know UNAIDS don't worry about it because they deny that unsafe health care plays a significant part in HIV transmission, and therefore refuse to investigate possible instances of it and they refuse to give proper estimates for its extent.

And the reason I say the person who infects the infant is only possibly their mother is that many infants have been identified whose mother is HIV negative (for instance in Mozambique and Swaziland). UNAIDS has tied itself in knots trying to argue that many babies are breastfed by a HIV positive person who is not the child's mother, etc. And while that might be a possiblity sometimes, it is unlikely to explain away all such instances.

Many women are known to become infected with HIV when they are already pregnant. Many are infected in the second or third trimester, even in the few months after they give birth. Now, I can't prove that women abstain from sex during and just after pregnancy. But nor do I think UNAIDS can demonstrate that most women don't abstain or, at least, reduce their coital frequency.

Nor can I prove that women don't have large numbers of unprotected sexual experiences with people who are not their partner during and just after pregnancy. But nor can UNAIDS demonstrate that they do. Indeed, the belief that African women, from a handful of African countries, sometimes from limited regions in those countries, engage in reckless sexually behavior ragardless of their own personal risk or circumstances, sounds to me like pure prejudice.

Sarah Boseley of the UK Guardian reports on a study questioning the suitability of antiretroviral treatment for young sufferers, a study which finds that very high rates of resistance result when people born with HIV are still young. And continued incidence of resistance is just a matter of time.

There is good and bad news for Sarah Boseley and for others who think that HIV rates in people born with HIV or who convert in their first few months or years is totally unacceptable: it is very likely that most mother to child transmission is preventable. And most of it is not just preventable in the way such transmissions are preventable in Western medical contexts, through careful support, treatment and medication.

It is very likely that a large percentage, perhaps the majority of transmissions, are a result of unsafe health care practices, injections, transfusions, intravenous drips and various other invasive procedures. After all, who believes that health facilities in high HIV prevalence countries are able to guarantee safety from transmission of HIV and other blood borne conditions? UNAIDS certainly doesn't.

The bad news is that little is likely to be done to reduce this kind of transmission because UNAIDS and other institutions who decide how HIV is transmitted (no, establishing how it is transmitted is not an empirical matter, don't be silly) have failed to investigate non-sexual transmission of this kind. In fact, they have refused to investigate, despite plenty of evidence that there is a case to be answered.

Is everyone comfortable with this? What makes the behavior of UNAIDS and those who follow their directives so despicable is that UNAIDS and other parties are well aware that a lot, perhaps a majority of HIV transmission, is a result of unsafe medical practices. It is not just a matter of sexual behavior. Africans do not have weired sex lives and they do care about their children, sexual partners, families and compatriots. Africans do not want their children to be born with HIV. But UNAIDS don't seem to mind.

Ever Increasing Numbers on Drugs is Not Reducing HIV Transmission

There's been a lot written about increasing the use of antiretroviral drugs, not just to treat people who are HIV positive, but also to reduce HIV transmission as well. One such strategy is called 'treatment as prevention', where those on antiretroviral treatment, under the right conditions, are said to be unlikely to transmit HIV to their sexual partners.

Another is called pre-exposure prophylaxis (PrEP), where HIV negative people take antiretrovirals because that has been shown to slightly reduce the risk for men who have sex with men, though not for women who have sex with men.

Reading the claims about 'treatment as prevention', you might think that it would make PrEP redundant. Advocates of treatment as prevention say that if a large proportion of the population in a high prevalence country were to be tested regularly, perhaps every year, and immediately put on ART if found to be HIV positive, transmission rates would drop rapidly.

But a group of researchers recently looked at sexual risk taking among patients on antiretroviral therapy in Nairobi's Kibera slum. And they note that many HIV treatment programs in such contexts do not include efforts to reduce HIV prevention beyond treating those already infected.

As a result, rates of sexual behavior considered to be risky remain high. It appears that, in their eagerness to get as many people on drugs as possible, the issue of preventing new infections has received little attention. And claims that this is not a problem, or even that it is not the case, sound rather hollow.

The researchers say "ART is often not enough to prevent HIV transmission, especially where there are high rates of inconsistent condom use and multiple sexual partners". Both these phenomena were found in Kibera.

Kibera may receive a lot more attention than most of the many slums in Nairobi. But the people living there only make up a fraction, perhaps a small fraction, of the total number of slum-dwellers in the city. Out of about 4 million inhabitants, as many as 60 or 70% may be living in slums.

It is noted that the tendency to treat people for HIV without also taking steps to reduce transmission is especially a problem in developing countries, which have weak health and social services. HIV prevalence in Kibera is estimated at about 12%, compared to 7.8% nationally.

People living in slums face multiple vulnerabilities, not just vulnerability to HIV transmission. Apparently "people living in urban informal settlements...have earlier sexual debuts, have more sexual partners, are more likely to use alcohol, and are less likely to adopt preventive measures against contracting HIV compared with urban residents in formal settings".

This research found that 28% of patients use condoms inconsistently (or not at all). Condom use was higher among those who were employed and among those who had been on treatment for longer. But women were three times more likely than men to report inconsistent condom use.

Married men were four times more likely to have had more than one sexual partner than married women, although only 9.5% in total said they had two or more sexual partners in the previous six months. Unmarried men were slightly less likely to have had more than one partner than unmarried women.

The context in which this research took place was described as "a relatively well-functioning ART programme with an inherent support structure focusing on patient education and information". But 'risky' behavior was still considered high, especially among those who had recently started ART, who are more likely to infect their sexual partners.

The authors conclude that "the roll out of ART cannot serve as a single preventive intervention, but must be linked with other preventive strategies for increased community effectiveness."

They also warn that "weak infrastructure and challenged health service delivery in informal settlements must be considered by policy makers and the donor community when developing future interventions to avoid the risk of negative effects, such as increased HIV transmission."

Putting more HIV positive people on ARV drugs has, for many years, led to very little money being spent on HIV prevention. While HIV positive people need treatment, and sooner rather than later, hundreds of thousands, perhaps millions of people have become newly infected with the disease.

Now those peddling drugs want to put HIV negative people on the same drugs, insisting that this will reduce transmission further. Drugs may reduce transmission, but neither of these strategies, treatment as prevention or PrEP, are identifying how so many people continue to be infected in somecountries and in certain parts of other countries.

Many African people live in conditions where the risk of being infected with HIV, either sexually or non-sexually, is very high. Neither of the above strategies even attempt to lower people's exposure to risk. Both of these exorbitantly expensive strategies, on the contrary, allow hundreds of thousands of people every year to be newly infected with a deadly disease.

[For more about pre-exposure prophylaxis (PrEP), see my other blog.]

Do Some Researchers Get Commission for Each New HIV Infection?

An article by Drs Robert van Howe and Michelle Storms entitled 'How the circumcision solution in Africa will increase HIV infections' brings together many of the arguments I have been putting forward about HIV and circumcision, but far more elegantly. And there are some arguments I haven't discussed as well.

The authors question the assumption that all HIV infections in the three often cited randomised controlled trials of male circumcision (in South Africa, Kenya and Uganda) resulted from heterosexual transmission. They argue that less than half resulted from sexual transmission and that therefore the majority of infections would not have been prevented by circumcision.

They argue that concentrating on mass circumcision will deflect attention and resources from effective HIV prevention work and may result in an increase in HIV risk. They recommend the promotion of correct and consistent condom use, which, unlike circumcision, is highly effective. If circumcised men think they don't have to use condoms, HIV transmission could increase considerably.

This argument also makes pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV negative people, said to reduce transmission by 44% when used by men who have sex with men, look like a very weak prevention strategy. PrEP also could lead to an increase in HIV transmission if it resulted in lower condom use.

The authors conclude that "a fifteen-fold increase in the circumcision rate would have the same impact as a 3.8% absolute increase in the use in condoms." So why not just concentrate on promoting the use of condoms and other complementary prevention strategies that actually work?

The authors also mention the barely mentionable iatrogenic HIV transmission which is clearly far more common in developing countries than UNAIDS and the HIV industry would like to admit. They comment: "Before Africans address sexually transmitted HIV, a concerted effort to eliminate the iatrogenic spread of the virus is needed."

They also note: "Condoms would be expected to be ineffective in regions where the majority of infections are from non-sexual transmission." Some authors, such as Drs David Gisselquist and Devon Brewer and Mr John Potterat have been writing on this subject for many years. But iatrogenic transmission is rarely mentioned in the official HIV literature and academic articles that discuss such concepts never seem to see the light of day.

Circumcision enthusiasts have concentrated their attention on populations where circumcision rates happen to be low and HIV prevalence high. But there are populations where circumcision rates are low and HIV prevalence is low. And there are populations where circumcision rates are high and HIV prevalence is high. It is hard to imagine why they have received so much attention, and presumably funding, when their overall stance is so unscientific.

But the vagaries of UNAIDS and the HIV industry have always been beyond comprehension to me. Meanwhile, massive rates of HIV transmission continue to occur in some of the most closely observed populations in the world. And yet those doing the observing don't seem to have figured out how HIV is being transmitted. Doesn't that ring alarm bells for anyone?

[For more about pre-exposure prophylaxis (PrEP), see my other blog.]

Underlying Factors in HIV Transmission Are Not Causes

When I was researching for a grant proposal to address gender based violence (GBV) and female genital mutilation (FGM) in the Mara region of Tanzania, I was unsurprised to find that HIV rates there are relatively low. High levels of violence, even GBV and FGM, do not necessarily lead to high levels of HIV. On the contrary, high rates of FGM are often correlated with low HIV prevalence.

This does not, as far as I am concerned, make GBV or FGM any less repulsive. But low prevalence of HIV in an area can sometimes make it difficult to attract funding. Low levels of nutrition, food security, education and other basic human rights are often ignored until it can be shown that HIV rates are high, or that rates are connected with other developmental problems.

Any claim that something is the 'main' driver of HIV is suspect, including an article on AllAfrica.com today entitled 'Women's inequality Main Driver of HIV'. Like GBV and FGM, all inequalities need to be addressed, because they are symptoms of underdevelopment, not because they are more or less related to HIV transmission.

Of course the "relentless cycle of vulnerability affecting girls and young women" needs to be addressed. But the attitude of UNAIDS and other institutions contributes to that relentless cycle. Telling whole populations that HIV is almost always transmitted through heterosexual sex gives rise to the sort of disempowering social and cultural norms and attitudes that such institutions claim to find so abhorrent.

The article correctly refers to staggering infection rates among women between 15 and 24 years but it does not refer to the fact that many of these women have only one partner who is HIV negative. Fewer men than women are infected in many countries and in some regions, rates among women are several times higher than those among men. It doesn't take people long to work out that something about what they are being told is not true.

Apparently 80 per cent "of young people, aged between 15 and 24 years, living with HIV are female". But most men are not infected until they are a lot older, well into their 20s, perhaps even their 30s. Why wouldn't some people think that HIV is introduced to populations by women? People know more about their own sexual behavior than they are sometimes given credit for, and if they or their partner become infected, they have a right to question the HIV orthodoxy.

All the HIV industry has succeeded in doing is in disempowering women further and undermining their efforts to change their situation. The industry has also further alienated men from wanting to bring about any kind of change. They have been branded as the main culprits in HIV transmission, in addition to all the other things they are accused of. They may not be innocent, but that's no reason to condemn them for something they are not all guilty of. And condemning them, rightly or wrongly, will not help bring about change, either.

Apparently men will be targeted in HIV campaigns that have so far mainly targeted women. But if this means further accusations of promiscuity, strange sexual practices and widespread antisocial behavior, it will prove as fruitless as most prevention work that has taken place so far. It will not be a new strategy, just another way of beating people over the head with the old strategy.

Another 'leading cause' of HIV often mentioned is illiteracy. Again, continuing high levels of illiteracy and profound inequalities in education are disgraceful after so many decades of development work. But HIV transmission has usually been found to be higher among the better educated (and richer) people in high prevalence countries. That wouldn't justify the claim that education 'causes' HIV, but nor should it justify the claim that illiteracy is a cause.

If UNAIDS are interested in what causes HIV, they should re-examine data about sexual practices and sexual transmission. They will find that some of the data is anomalous if it is assumed that almost all HIV is sexually transmitted but the anomalies disappear once they allow that some HIV is transmitted non-sexually.

Reliance on mathematical models is unwise when it comes to estimating the contribution of various modes of transmission because this can lead to circularity. But HIV prevention will be a whole lot easier when it begins to target genuine causes, rather than mere underlying factors.

It is Sweet and Beautiful to Die for One's Scientists

A little while back, I blogged about research that identified HIV prevalence 'hotspots', where high figures were clustered together. This research, carried out in Lesotho, looked at hotspots for males and females and found that they were spatially distant, which may seem anomalous for what is said to be a mainly sexually transmitted disease.

Similar work carried out in South Africa was a bit disappointing. Because, even though it is well known that fewer men are infected than women, often far fewer, this research by Handan Wand and Gita Ramjee only looked at hotspots of high HIV prevalence and incidence for women [Apologies for providing the wrong link yesterday.] Excluding men from such research is odd if it is assumed that women are mainly being infected by men.

But it clearly is assumed that all, not just almost all, transmission is through sex. "At all visits, all participants received counselling on risk reduction and as many male condoms as desired. Counsellors emphasized that condoms are the only known method to prevent HIV and sexually transmitted infections (STIs), and that condoms should be used for every act of sex."

There is something small but crucial wrong with this statement: condoms are the only known method to prevent sexually transmitted HIV. But using condoms during sex will not protect against non-sexually transmitted HIV, which could result from unsafe health care or unsafe cosmetic practices.

Indeed, failing to inform people about non-sexual risks means that they are unable to protect themselves from them and this could be a reason why HIV prevalence is so high in some sub-Saharan African countries. Pretending that HIV is always (or even almost always) sexually transmitted flies in the face of all evidence and is probably responsible for a substantial proportion of all transmission.

As for this research, it found some significant correlations between being HIV positive and certain types of behavior considered to increase the risk of being infected with HIV. 'Significant' in the strict statistical sense of the word, but not particularly large correlations. A non-statistician might think the data needs to be re-examined in the light of such apparently minor differences but not our intrepid authors.

For example: "The proportion of women who reported being legally married was significantly higher among those outside the hotspots than within them (16% vs. 12%, p = 0.001). Significantly more women in the geographical hotspots reported being Christian (94% vs. 90%, p < 0.001) and speaking Zulu at home (91% vs. 86%, p < 0.001) compared with those in non-cluster areas."

The article goes on: "The spatial clustering of HIV cases was found to be related to certain demographic and risk behaviours. Number of male sexual partners was not collected in this study; however, being single, combined with high frequency of sexual acts, gives strong evidence for those women having multiple partners, as well as possibly engaging in transactional sex."

'Strong' evidence? How does this 'high frequency of sexual acts' compare to countries with low HIV prevalence? The same question regarding 'multiple partners'? And would the authors come to the same conclusion of 'possibly engaging in transactional sex' if the risk factors in a low prevalence country were similar? I don't think so.

The authors may be leaving the door open to further research about the safety of health care facilities, but then again, they may not: "These results may be due to fundamental differences between the communities with regard to health care centres, population density and other socio-economic factors. These data provide new evidence to support the need to investigate potential sources of infection and to study transmission patterns in the community in order to apply relevant interventions for prevention of this devastating disease."

Let's hope that 'relevant' interventions means interventions that prevent non-sexual as well as sexual transmission, but it doesn't look as if these particular researchers will see things that way.

It is concluded that "Information on the spatial distribution of populations and services is essential to understand access to health services." But if some HIV is being transmitted nosocomially, as a result of inadequate health facilities, this also needs to be established. Otherwise increasing access to health services could result in higher rates of HIV transmission.

The authors don't just need to "determine and target the specific communities that are most in need of education, prevention and treatment activities", they also need to determine exactly what sort of education and what sort of prevention activities are required. Otherwise, at best, things could remain as bad as they are and atworst, they could get a lot worse. Neither of these would be good for South Africa.