Thursday, October 19, 2017

Via Negativa: the way to low HIV prevalence?

Wajir is a city and county in Kenya’s former North Eastern Province. From a HIV perspective, the county stands out for having the lowest prevalence of all Kenya’s 47 counties, currently estimated at 0.4%. The next highest counties are Mandera (0.8%) and Garissa (0.9%). Wajir, Mandera and Garissa make up what was the province, formerly a part of Jubaland, in Southern Somalia.

Homa Bay is a town and county in the south west, formerly part of Nyanza Province, and the number one county for HIV prevalence, 26%. Indeed, the only counties with prevalence above 10% are Siaya, Kisumu (19.9%), Migori (14.3%) and Homa Bay, which (along with Kisii and Nyamira) made up Nyanza. That accounts for one third of all HIV positive people in Kenya.

The question of why HIV prevalence is so high in certain parts of Kenya is usually answered, implicitly or explicitly, with half baked notions about ‘African’ sexual behavior, ‘African’ mores, ‘traditions’, sexual practices, ‘unsafe’ sex, promiscuity. In a word: sex. It’s all about sex, and in the worst hit counties experts have persuaded the US to part with hundreds of millions of dollars for mass male circumcision programs.

A lot less seems to be written about the extremely low HIV prevalence found in the north east. Look up Mandera, Garissa or Wajir on PubMed and you will only come across just over 300 papers altogether, compared to thousands for other locations (and almost 50,000 for Kenya as a whole). But it would be interesting to know how HIV prevalence has remained as low as in many western countries in the north west of Kenya, yet it has risen as high as the worst hit countries in southern Africa in the south west of Kenya.

Sex happens in north eastern counties too. In fact, condom use is generally lower in these counties. Polygamy is more common, as are intergenerational sex and marriage, phenomena the HIV industry sometimes insists are risks for HIV transmission. Knowledge about HIV transmission and how to avoid it tends to be lower in these counties, too. Birth rates are higher than in other parts of the country.

Circumcision is said to be widespread in a number of counties, not just in Wajir (and Mandera and Garissa) but also, for example, in Kilifi. But HIV prevalence in Kilifi is a lot higher, at 4.5%. The populations are predominantly Muslim in both counties, so circumcision is not likely to be the full explanation, nor is religion. There are commercial sex workers and men who have sex with men in every county, with no evidence that these practices are less common in low prevalence counties.

The north eastern counties are, in fact, very different from the rest of Kenya. Kenya was divided up on ethnic lines by the British, which is why the territory once called the ‘Northern Frontier District’ became one province: it was, and still is, populated by ethnic Somalis. They are geographically isolated, in the sense that there are few major roads. Much of the north of Kenya is arid and sparsely populated. Even the Somalis who live elsewhere in Kenya, such as in Nairobi, tend to live in predominantly Somali suburbs.

A similar kind of isolation, albeit on a much larger scale, can be found in northern Africa. The Sahara is sparsely populated and there are few major roads traversing it. HIV prevalence is low in all North African countries. In fact, HIV arrived relatively late in North Africa, and analysis of the common subtypes there suggest that the epidemic spread to a large extent from southern Europe, and to a lesser extent from West and central Africa.

The most common HIV subtype in Kenya is type A, followed by D, with a small proportion of type C. But the most common subtype in the north east of Kenya is type C, this being the most common subtype in southern Africa, Ethiopia and a number of other countries. So the former province really does seem to have a different epidemic or ‘subepidemic’. Type C is known to have evolved later than A and D, so the former North Eastern Province’s subepidemic is newer, like those in North African countries.

But it is still unclear how the above features of certain epidemics and subepidemics are associated with very low prevalence. Instead of looking for phenomena behind very high prevalence in some south western counties, are there certain phenomena that are absent in the north west (and in North Africa)? Isolation doesn’t mean less sex, nor even less ‘unsafe’ sex, and sexual behavior is very poorly correlated with HIV transmission.

We don’t know much about Wajir, Mandera and Garissa because not much research has been carried out there, and it’s not surprising that little HIV research has been carried out where there's little HIV transmission. But what about other healthcare research? I notice almost all the articles on PubMed are about HIV, and were published in the last 20-30 years. So the area has been isolated from research for a long time.

Now, if there are few roads and limited infrastructures, is healthcare infrastructure similarly limited? It could be expected that access to healthcare facilities is poor and that many people rarely or never go to a hospital, or see any kind of health professional. The majority of women probably give birth at home, coverage of mass drug administration programs, including routine immunizations, is probably lower for these and other more isolated counties.

Borrowing Nicholas Nassim Taleb’s ‘via negativa’ in his book ‘Antifragile’, perhaps HIV prevalence in the north east of Kenya (and in North Africa) has remained low because of infrequent contact with healthcare facilities. This is not to say that healthcare facilities are unsafe in the north east, although it does suggest that they are unsafe in high prevalence counties. Also, it is suggested that HIV is circulating in health facilities, more in some than in others.

Many (including Taleb) like to repeat that ‘absence of evidence is not evidence of absence’. There is a possibility that HIV has been, and is still circulating in health facilities in Kenya, and may account for a significant proportion of infections, perhaps the majority of infections. Little research has been carried out to estimate the relative contribution of healthcare associated HIV transmission. We will never know until the evidence is sought: does limited contact with healthcare keep HIV prevalence low in the north east of Kenya?

allvoices

Wednesday, October 11, 2017

UNAIDS: Still Spanking the Chimp

How are we to make sense of a HIV epidemic such as the one in Uganda? We are told that it is mostly a result of ‘unsafe’ sex. But data about sexual behavior in Uganda is unremarkable; most people don’t engage in high levels of unsafe sex, and types of sexual behavior considered unsafe appear not to be so unsafe after all.

In 2007, it was estimated that there were almost one million people living with HIV, 135,000 newly infected with HIV in that year, and 77,000 deaths from Aids. The Demographic and Health Survey for Uganda in 2011 concluded that “Differences in HIV infection according to higher risk sexual activity are minor”.

In fact, the vast majority of the 18,000 people surveyed did not engage in sexual behavior considered to be risky. Most people had a maximum of one partner in the last 12 months, most who had more than one partner did not have concurrent (overlapping) partnerships, most did not report large numbers of lifetime partners, most didn’t pay for sex and most didn’t engage in ‘higher risk’ sex in the past 12 months.

So it’s hard to believe that the table appearing on page 15 of the Modes of Transmission Survey (MoT) for Uganda, for 2009, can be anything but fiction. It claims that almost 90% of HIV incidence is a result of multiple partnerships, partners of multiple partnerships and people engaged in mutually monogamous heterosexual relationships.

Even incidence attributed to sex workers doesn’t reach 1%, nor does that attributed to men who have sex with men, plus their female partners. Injecting drug use doesn’t play a big part in most of the epidemics in sub-Saharan Africa either.

The DHS figures for Uganda clearly do not support the MoT figures. They do not support the contention that high HIV prevalence indicates high rates of ‘unsafe’ sexual activity; HIV prevalence is high in Uganda, but sexual activity is not exceptional, nor is it closely associated with HIV transmission.

DHS continues: “HIV prevalence by the number of sexual partners in the 12 months before the survey does not show the expected patterns”. It is noted that “HIV prevalence shows the expected relationship with the number of lifetime sexual partners” but the author doesn’t mention that the numbers of people involved is very small. So they conclude that “it is important to remember that responses about sexual risk behaviours may be subject to reporting bias”.

Uganda was one of the first countries to expose itself to the scrutiny of the rapidly developing HIV industry, from the 1980s. As a result, a lot more studies took place there, a lot more papers were published about Uganda and tens of millions more dollars were spent there than in any other African country, even countries that later turned out to have far worse epidemics.

It takes more than a bit of fluffing to get from the Demographic and Health Survey’s flaccid data on sexual behavior to the conclusion that almost 90% of HIV transmission is a result of unsafe heterosexual sex. But if the industry doesn’t come clean about where the bulk of new infections are coming from, resources targeted at those thought to or claimed to engage in ‘unsafe’ sex will continue to be wasted.

allvoices

Thursday, September 28, 2017

HIV: A Rich Seam in a Long Abandoned Mine?

Here's a stomach-churning quote from The Eugenics Review, 1932: "East Africa [has] a heavily syphilized native population", where tests suggest that "not less than 60 per cent. to 70 per cent. of the general native population" have some kind of sexually transmitted disease.

At that time, several conditions were mistaken for syphilis (or other STIs). For example, yaws and endemic syphilis, neither of which are sexually transmitted. Prejudices about 'African' sexual behavior were used to prop up beliefs about prevalence of STIs (and prejudices about STIs proped up beliefs about sexual behavior).

You might think that things would have moved on a bit, what with eugenics no longer having the cache it had in the thirties, right? But the received view of HIV in high prevalence countries is that 80-90% of transmission is a result of sexual behavior, mostly heterosexual behavior.

From this 'expert’ opinion about ‘Africa’, it is assumed that high HIV prevalence indicates high rates of 'unsafe' sexual behavior, and that high rates of 'unsafe' sexual behavior (or rates that are assumed to be high) indicates high HIV prevalence, or that prevalence will reach high levels in the foreseeable. It’s pretty easy to spot the pig-headed circularity in the argument.

So, how far have we moved on 80 years after the Eugenics Review quote, above? Here’s Catherine Hankins, from the Amsterdam Institute for Global Health and Development (formerly a senior officer in UNAIDS):
As Hankins surmises, in some cultures what you do with your sexual partners over time is different. In the West we tend to be serially monogamous.
In Africa, if you've had sex with someone at some point, the door isn't considered closed on picking up on that relationship again.
"Take a middle-class African businessman. He has had five women - nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a 'deuxième bureau' - a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.
"Within a year he may have infected four other women. Now, if I've had five sexual partners and catch HIV from the fifth, as a western woman I'm unlikely to return to the other four and infect them!"
You might object that it is unfair to criticize what is clearly just an opinion, however ‘expert’. But policy is based on such opinions, HIV programs are guided by them, enormous amounts of money are spent (entirely in vain) on them. Worse still, the scientific data so assiduously collected shows that Hankins is as wrong as the eugenicists. Ostensibly, at least, Hankins was responding to scientific findings, published in a scientific journal, not to someone's opinion.

You can look through any Demographic and Health Survey you like, where you will find numerous tables about sexual behavior, family life, people’s ability to recall selective tidbits about HIV, etc, but you will not find a country where a large number of people have lots of sexual partners, or engage in sexual activities considered to be unsafe.

In addition, the circularity mentioned above comes across very clearly in Hankins’ invective: HIV prevalence is high because rates of ‘unsafe’ sexual behavior are high, and we know about sexual behavior because HIV prevalence is high. Hankins clearly believes all these prejudices that she expresses about sexual behavior among ‘Africans’!

Three countries account for about one third of all HIV positive people, globally; South Africa (6.8m), Nigeria (3.2m) and India (2m). The same three countries also accounted for more than half of all aids-related deaths in the past few years. It is notable that prevalence is low in India, at less than 0.3%. This compares to about 3% prevalence in Nigeria, and about 19% in South Africa, more than 60 times higher than in India (and it can rise to well over 100 times higher in certain demographics).

Whatever is behind the huge rates of HIV transmission in these countries, which tend to be concentrated in certain geographical areas and populations, it is likely to be something that is amenable to scrutiny, whether it involves the copious quantities of sex that UNAIDS would claim, or something else, for example, dangerously low standards of hygiene and infection control in some health facilities.

Hankins seems intent on mimicking the media approach to HIV, concentrating on relatively rare and infrequent phenomena (deliberate transmission, ‘virgin cures’, fake healers, ‘traditional’ practices, etc), but failing to notice the appalling conditions in healthcare in some of the areas worst hit by HIV. What is it that is deflecting attention from everyday phenomena, allowing such extreme views to prevail, but failing to reduce infections in the worst hit areas?

allvoices

Friday, September 15, 2017

Pre-Exposure Prophylaxis: Risks in the Pipeline?

An estimated 1 million Kenyans are receiving antiretroviral drugs, about 64% of all HIV positive people. Partly as a result of this, death rates, along with the rate of new infections, have continued a decline that started in the early 2000s, and the early to mid 90s, respectively. Now pre-exposure prophylaxis (PrEP) is being added to the country’s HIV strategy, a course of antiretroviral drugs taken by HIV negative people, which should significantly reduce the risk of their being infected.

So this should be a good time to look at how HIV treatment in its various forms should be targeted. ARVs are relatively straightforward, people testing positive can be put on treatment. But PrEP, if it is expected to reduce infections, needs to be prescribed for those most at risk. This is not as simple as it sounds, because HIV resources have so far been flung far and wide in Kenya, as if those who most need them will magically benefit.

The ruling assumption for high prevalence countries has been that 80-90% of all HIV transmission is a result of ‘unsafe’ sexual behavior. HIV prevalence is seen as a reliable indicator of ‘unsafe’ sexual behavior, and ‘unsafe’ sexual behavior, or perceived behavior, is seen as a reliable indicator of prevalence.

This is completely circular, of course. But if these prejudices are carried over from addressing the HIV positive population, and applied equally to the HIV negative population, the bulk of the drugs may as effectively be flushed down the toilet. The majority of Kenyans are, were, or will be sexually active. But the majority are not at risk of being infected with HIV.

Kenya’s HIV epidemic, in common with the epidemics in several other East African countries, is quite old. The virus has been circulating since the 50s and 60s, so the epidemic is about half a century old, give or take a few years. In other countries, such as the DRC, the virus has probably been around for about 100 years, although it must have affected only small numbers of people for many decades.

Don’t be fooled by figures suggesting that HIV has only been around since it was first recognized by doctors in the early 1980s (or just a little bit earlier), and later described by scientists. UNAIDS estimate that prevalence was already about 3% in Kenya by 1990, rising to over 10% later in the decade, to peak at almost 11%. From 2000, prevalence declined for a few years, rose again from 2005, then dropped to 6%.

This suggests that the rate of new infections (incidence) peaked and started to decline in the early to mid 90s, prevalence peaked and started to decline by the late 90s, and death rates would have peaked in the early 2000s. By 2007 prevalence was 8% and it is now 6%, so it has hovered between 6 and 8% for more than 10 years. Declines are slow, irrespective of major interventions.

Although the widespread use of ARVs, which began in the late 2000s, has contributed to a decline in new infections, prevalence and death rates, it is not possible to attribute these improvements to drugs alone. Making PrEP available to all those assumed to be ‘at risk’ of being infected, purely on the basis of the circular argument mentioned above means that this is going to be an expensive, but very ineffective intervention.

This sounds like bad news, but it doesn’t have to be seen that way. If the HIV risks people face could be identified, whether they are sexual or non-sexual, this will reduce the number of people who need PrEP. Most non-sexual risks, for example, exposure to blood and other bodily fluids through unsafe healthcare, cosmetic and traditional practices, are easily and cheaply avoided. No need to give PrEP to all the patients at a clinic when you could just clean up the clinic, right?

But also, things have changed, PrEP allows us to target those most at risk much more accurately than before. If people know they can protect themselves, they will. Clinics can now safely return to the practice of ‘contact tracing’, identifying how each person testing positive may have been infected, and then addressing that source of infection, whether it was a sexual partner, a clinic, a tattoo artist, or whatever.

The decision to discontinue tracing contacts, which was made in a very different context (a rich country, where the bulk of HIV transmissions were occurring among a relatively small population, and resulting from an easily identified set of behaviors) is inappropriate for a country with a massive HIV epidemic, where the risks have not been clearly demonstrated, and averted. In Kenya, for example, the majority of people who become infected with HIV do not face the high risks identified in rich countries, receptive anal sex and injecting drug use.

If identifying how people become infected can allow HIV negative people to avoid being infected, and allow HIV positive people to avoid infecting others, then contact tracing is vital in high prevalence countries. It is also vital if interventions such as PrEP are to be effective, or even affordable. Already, researchers have found that not being able to identify where the risks are coming from will significantly increase the quantity of drugs each person needs, in addition to vastly increasing the number of people deemed to be in need of PrEP.

Despite ample evidence that non-sexual risks are as important as sexual risks, evidence that has been available since the virus was first identified as causing Aids, most research concentrates on reporting sexual risk only, collecting data about sexual risks, recommending strategies to reduce sexual risks only, while ignoring, denying or failing to collect data on non sexual risks.

Mass ARV rollout complements pre-existing trends in HIV epidemics, though not as much as it could have, had the contribution of non-sexual transmission been acknowledged. However, PrEP will be a slow and inefficient solution unless targeted at those truly at risk, as opposed to the tens or hundreds of millions who are sexually active. People can only protect themselves if they know what the risks are, whether they do it by avoiding exposure, or by taking prophylactic drugs.

allvoices

Tuesday, September 12, 2017

HIV in 'Africa':12 Steps to Unknowing Knowns

Sometimes it’s hard to believe that both sexual and non-sexual transmission routes for HIV were recognized in the early 1980s, even before the virus had been identified. Some of the earliest responses included recognizing lack of infection control in health facilities, and transmission rates are likely to have been cut substantially as a result of these responses alone.

The bulk of transmissions in rich countries, such as the US, are still accounted for by male to male sex, with a far smaller proportion being a result of injected drug use. But in poor countries, especially sub-Saharan African countries, where the majority of HIV transmissions occurred and continue to occur, most people infected are not men who have sex with men, nor injected drug users.

The ruling assumption behind HIV ‘strategies’ in high prevalence African countries became ‘promiscuity’. UNAIDS and the HIV industry grew up around claims that 80-90% of HIV transmission in African countries is a result of ‘unsafe’ heterosexual sex. Given the low probability of transmission during heterosexual sex, long-held notions about ‘African’ sexuality were dusted off, and spawned the behavior change industry.

Sex (among Africans, of course) came to be presented as an addiction, a pathological condition. Predictably, one of the most popular approaches to addiction, The Twelve Steps, was adapted for the behavior change sector. Billions of dollars were wasted on programs that were shaped by familiar assumptions about what ‘African’ men do to ‘African’ women, and how frequently.

It’s not clear how much George W Bush himself was involved in earlier versions of behavior change and abstinence only programs, claimed to reduce HIV transmission (and, eventually, eradicate it altogether). But he is likely to have been familiar with the Alcoholics Anonymous program, given his own experience with drink (and evangelical religion).

It would be tedious to go through every step individually, but it’s worth broadly comparing the 12 steps with received views about HIV in ‘Africa’. Aside from connections with a ‘higher power’, confessions, testimonials, evangelism and notions of ‘rescue’ or being ‘saved’, there’s also the oppressive emphasis on ‘abstinence only’ that has been the downfall of all 12 step programs, whatever they aimed to remedy.

It’s like the line in the movie ‘Burn Before Reading’: “Fuck you, Peck! You're a Mormon! Next to you, we all have a drinking problem!” All sex (in ‘Africa’) is ‘unsafe’ sex, all sex is wrong, all sexually active people are ‘promiscuous’, all HIV is either a result of ‘unsafe’ sex, or of contact with someone who engaged in ‘unsafe’ sex.

Why is the HIV industry so firmly wedded to abstinence only programs? They have failed for drink, drugs, sex, gambling, eating, smoking, etc; abstinence-only just doesn’t work. Since all the serious HIV epidemics in sub-Saharan African countries peaked and started to decline, mostly before these behavior change programs had been deified, many millions of people have been newly infected.

If sex were the only risk for HIV, almost everyone would be able to protect themselves, and most would do so. There would only be a minority for whom sex is an addiction, an occupational hazard or unavoidable risk that exposes them to HIV, STIs and other hazards. Most sexually active people are not ‘promiscuous’, and recognizing this is key to reducing HIV transmission in sub-Saharan Africa.

allvoices

Thursday, September 7, 2017

Choke on it: Peak Free Lunch at HIV Inc?

There have been several mentions recently of significant cuts in HIV funding, including PEPFAR and the Global Fund for Aids, TB and Malaria. It is said that funding could be cut by several billion dollars per annum, even as much as one third of all funding. Should we be worried?

According to UNAIDS, funding available for low and middle income countries has grown from $4.8 billion in 2000 to $19.5 billion in 2016. During that time, deaths from Aids have dropped from a peak of 1.9 million people in 2005 to 1 million in 2016.

The number of new infections has gone from about 4.7 million in 1995 to 1.8 million in 2016 and the number accessing treatment has gone from 685,000 people in 2000 to 19.5m people in 2016. The fear is that the number of deaths will cease to drop, or even increase, as the number of people on treatment flattens out or drops.

The gains over the last 15 years are certainly impressive, especially the increases in funding. But the correlation between increases in funding and improvements in HIV indicators is not so clear. Drops in rates of new infections had started many years before, and even death rates had peaked and started to decline before funds such as PEPFAR and GPATM would have had much impact.

In fact, figures for new transmissions in some high prevalence countries started to drop in the 80s (Uganda) and 90s (Kenya and Tanzania), long before big funding and large treatment programs were available. By the 2000s, several countries with serious epidemics were already seeing a substantial downward trend (Zimbabwe), with only an occasional upward blip, such as that experienced in Uganda.

Here are some ways that a lot more could be achieved with a lot less money:
  • Trace the possible source of every new infection; every new infection is potentially the source of more than one further infection, so failure to trace sources represents one of the biggest missed opportunities of the last 30 years of providing HIV services
  • Offer non-HIV healthcare services to those who test negative (as an incentive to testing), eg, free treatment for conditions other than HIV, including STIs
  • Re-examine the relative contributions of non-sexual and sexual infection routes for HIV, which must vary considerably from country to country, even within countries
  • Re-integrate HIV clinics and services into other health facilities, getting rid of expensive parallel HIV-specific structures
  • Distribute funding at a level closer to people on the ground, such as HIV positive people and those providing services
  • Re-direct some of the remaining funding to improving safety in certain service areas, eg, maternal health
  • ‘No blame’ investigations into serious outbreaks, especially among those whose risk should be low, eg, maternal health beneficiaries, virgins, infants, etc
  • Drop failing programs, such as abstinence-only and other behavioral programs that are aimed solely at sexual behavior
  • Listen to leaders who are calling for positive change, for things to be done differently, for a re-think of some of the strategies that have been failing for a long time
Big reductions in HIV funding could be used as an opportunity to make positive changes in the way the remaining funding is spent, and allow each dollar to go much further. Country leaders need to think differently, rather than chaining themselves to strategies that have been failing for years. Massive HIV NGOs and other institutions are too far removed from individual epidemics to be able to see differences between countries and within countries.

What we should worry about is stasis: static thinking in HIV institutions, static research focus in universities, static behavior in health facilities, static attitudes that have not moved on from the sensationalist finger-pointing of the 1980s. Static or falling funding is irrelevant so long as HIV spending remains independent of what’s happening on the ground. A radical drop in funding may bring about the very changes that have been wanting for decades.

allvoices

Monday, September 4, 2017

Mandatory HIV Tests: Shouldn’t Zambians Decide?

The Lancet has an article by Andrew Green about the recent decision of the government of Zambia to introduce mandatory HIV testing in all government health facilities; if they visit a clinic, they must agree to be tested. Green urges against mandatory testing, using the often heard claim that people will be reluctant to go to health facilities if they think they will be compelled to take a HIV test.

It is argued that people could feel ‘stigmatized’ if they are found to be HIV positive, or perhaps even if they are just tested for it. Indeed, the orthodox view of HIV is that it is almost always sexually transmitted in African countries, and that there are excessively high levels of ‘promiscuity’ (in case you were wondering where the stigma comes from). Popular supporters of the orthodoxy Avert.org, write: “Unprotected heterosexual sex drives the Zambian HIV epidemic, with 90% of new infections recorded as a result of not using a condom”.

Zambia ranks 7th in the world by HIV prevalence, around 13%, and 9th by number of people infected with the virus, about 1.2 million. The epidemic in Zambia probably started before the 80s because it had already reached 9% prevalence by 1990. Prevalence has stood at over 10% for about 25 years. It peaked in the mid 90s, so it has only dropped by a few percentage points in the past two decades. Population growth would suggest that new infection rates have not dropped at all.

Health Minister Chitalu Chilufya told Green “We can't continue doing things the same way and hope that things will get better”. Chilufya is a doctor, not just a politician, and it’s hard to disagree with his response. What has been done so far has failed. The epidemic has remained ahead of the HIV industry, with 60,000 new infections a year, far outnumbering the 20,000 deaths from AIDS. Maybe it’s time to do something different?

Green cites the World Health Organization as an authority for the view that testing should not be mandatory or coerced. But where does the view that people will stop going to health facilities come from? Is there any country that has made testing mandatory, and found that people stopped seeking healthcare of any kind? Perhaps people are more reluctant when it comes to HIV because they know that it is seen as an indication that they have been ‘promiscuous’. Might they be more willing to be tested if WHO drops their mantra about sexual transmission?

Cuba is an example of a country that has taken a very different path from almost every other country when it comes to HIV, and healthcare as a whole. Most countries are heavily influenced (dominated?) by the WHO, or by US funding and HIV ‘policy’. But things in Cuba couldn’t be more different from Zambia, and sub-Saharan Africa more broadly, with one of the best controlled HIV epidemics in the world.

The UNAIDS current ditty is ‘90-90-90’, at least 90% of HIV positive people tested, at least 90% of those found positive on medication and at least 90% with an undetectable viral load by the year 2020. So, what is their strategy to achieve this, aside from assuming that everyone should continue to copy all the failed strategies of the US, hoping that things will be different for them?

Targeting people thought to be at risk of HIV purely on the basis of their perceived levels of ‘promiscuity’ means those infected non-sexually, or at risk of being infected, will be missed. Unless they start to estimate non-sexual transmission sources, and start to reduce transmissions of this type, untold numbers of Zambians will be infected, and can go on to infect others, directly or indirectly.

If the orthodoxy are confident that 90% of HIV infections are sexually transmitted, they have nothing to lose by tracing people’s contacts, sexual and non-sexual. This doesn’t violate anything. HIV positive people have a right to know how they were infected and HIV negative people have a right to know how to protect themselves from risks. But if Zambia 'returns to the flock', and keeps all testing voluntary, what rights might this threaten?

If contacts are not traced, many people won’t know what the risks are, and therefore how to protect themselves. HIV positive people won’t know for sure how they were infected. According to the Lisbon Declaration on the Rights of the Patient, people are entitled to be informed of things like this by their health facilities, by healthcare personnel. People are also entitled to accurate health information and education. Where is this accurate information to come from if health facilities don’t collect it, or if it is never analyzed or followed up?

People have a right to know about hygiene, safety and infection control in health facilities, and similar information. It would be obtuse to argue for a right to health or healthcare, but against ensuring safe healthcare. In any population, including Zambia’s, there are unexplained transmissions. Examples include HIV positive virgins (who were not infected through mother to child transmission), HIV positive people who have never had sex with a HIV positive person, HIV positive people whose only sexual partner has tested HIV negative, HIV positive infants whose mother is negative, etc.

Green seems to be arguing on behalf of an orthodoxy that is afraid people will realize that there are non-sexual risks, as well as sexual, and that people have been systematically denied their right to this information. He seems to want to help cover up the fact that possible non-sexual infections that may point to unsafe healthcare, for example, have never been investigated in high HIV prevalence countries, or any countries whose HIV strategy is entirely dominated by the WHO, CDC, UNAIDS and the like.

Rather than challenging opposition to mandatory HIV testing, perhaps Zambia could investigate possible healthcare associated transmission of HIV. There is no violation involved if non-sexual contacts are traced, such as unsafe healthcare, traditional practices, or even cosmetic practices, such as tattooing. If Zambia doesn’t do something different, the epidemic could follow the Lindy Effect, lasting another 40 years. But the matter should be decided by Zambians, not by The Lancet.

allvoices

Friday, September 1, 2017

America's Other Epidemic: HIV in Confederate States

Almost 70% of new HIV infections each year in the US are a result of male to male sex. The other 30% results from injecting drug use and non-male to male sex. But prevalence varies considerably from state to state. An estimated 45% of all HIV positive people live in the southern region of the US. Prevalence is also high in some northeastern states, especially in some cities.

The southern region consists of Alabama, Arkansas, Delaware, Dist. Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia. Prevalence is highest in the District of Columbia; at 3.61% that's higher than in 138 countries. Florida has the highest HIV positive African American population, 48,500 people, higher than in 109 countries.

In the southern states, an estimated 55% of the people living with HIV are African Americans. The figure for the Midwest is 47%, 42% for the Northeast and 18% for the West. Although African Americans only make up just over 13% of the population, almost half live in southern states, about 22 million people. And HIV prevalence among African Americans in southern states is 7 times higher than it is among white Americans.

Prevalence in every southern state is several times higher among African Americans than it is among white Americans; it’s 3 times higher in the District of Columbia and 9 times higher in Maryland. In 2014, almost half of all new HIV infections in the US were among African Americans and two thirds of people living with HIV in southern states are African Americans.

The contrast is also stark for heterosexual HIV: there were more than 4,600 female African Americans infected, compared to just over 1,100 female white Americans infected. Infections classified as ‘white heterosexual male’ are low in number, whereas an estimated 2,000 were classified as ‘black heterosexual male’.

Why would sexual behavior among African Americans, homosexual and heterosexual, be more risky than sexual behavior among white Americans? And why would sexual behavior be exceptionally risky in southern states? Or is there more to high HIV prevalence than levels of sexual behavior and types of sexual practice?

To put it another way, do African Americans tend to conform to the many stereotypes about them, such as levels of sexual behavior, types of sexual behavior, attitudes towards sex, etc? Or are there things about the environment, such as living conditions, economic and social conditions and conditions in healthcare facilities, for example, that increase the risk of infection that African Americans face?

It’s hard to know what conditions, exactly, could increase risk to such a degree, or even how. But there certainly are factors that are particularly acute in southern states. The bottom 11 states for life expectancy are in the southern region, as are most of the states with the highest incarceration rates. Almost all the poorest states are in the south. States with the lowest rankings for educational attainment, at all levels, are in the south. Rates of unemployment and homicide rates are high.

Of course, some of the southern states are among the richest by GDP, with the highest household income. But they also have the some of the highest levels of inequality, with several states ranking lowest for economic indicators and several ranking poorest in the US. As a result, most of the states with the lowest Human Development Index are in the southern region. Rates of religiosity are high.

Some sexual practices are low risk for HIV, some are high risk. But why do African Americans, gay and straight, face far higher risk of infection than white people? Prevalence in Somalia, Senegal, Niger, Sudan, Morocco, Tunisia and Egypt is lower than in the US (.6%). Prevalence in Burundi, DRC, Liberia, Burkina Faso, Eritrea and Mauritania is lower than in the US south (1.12%). HIV prevalence does not correlate well with sexual behavior data. So what other factors could be involved?

allvoices

Wednesday, August 30, 2017

Is that Guardian Article Really Racist?

Accusations of racism against the two journalists (Samuel Okiror and Hannah Summers) who put their names to an article entitled “'Why are you having sex?': women bear brunt of Uganda's high HIV rate”, and even The Guardian itself, may sound unwarranted, insolent, even arrogant. Is The Guardian guilty of ‘deep racism in patologizing sex’?

No questions are raised about the long held assumption that HIV is ‘all about sex’. The authors seem to make the same assumption themselves. They don’t question people’s right to health information and to health education, which sex education is only a part of. These rights are very clearly stated in the World Medical Association’s Lisbon Declaration on the Rights of the Patient.

What about Uganda’s ban on sex education? The Guardian could have mentioned that, if they feel that this is so relevant to HIV. The tone and content of sex and sex education articles tend to be quite different when they are about sex in a UK or non-African context. Similarly with ‘Aids and HIV’. In the UK, people have a right to privacy, for example, but not in African countries, where a HIV positive diagnosis is assumed to indicate ‘unsafe’ sex, regardless of what the person may report.

The Guardian doesn’t wag its finger at adult men who have sex with adult men and tick them off about their ‘promiscuity’. But finger-wagging at adult men and women in high HIV prevalence countries in parts of Africa is routine, as if they are behaving like disobedient children. The Guardian doesn’t seem to notice these double standards.

The question ‘Why are you having sex? You should be married’? is said to be an instance of discrimination against young females who attempt 'to access HIV prevention services from the health sector'. But the Ugandan health sector is shaped and funded by an international community that insists that HIV is all about sex. The 'stigma' to which the article alludes comes from the HIV community, from the media, from governments and international communities.

Why more young girls than young boys: "Health experts have attributed the disparity to the fact men tend to have more sexual partners, so a man with HIV would spread the infection to more people". Aside from the logistics of that 'expert' opinion, it also seems to be based on the assumption that sex is usually instigated by men, with women usually being unwilling victims, that men are ‘more promiscuous’ than women, etc. Or perhaps those assumptions are totally absent?

While we are questioning differing prevalence rates by gender, what about some of the other figures gathered for Uganda and elsewhere (see Uganda Aids Indicator Survey, 2011 and others)? For example, why are there often large numbers of HIV positive virgins, who were not infected vertically? There have been cases of babies who seroconverted even though their mother were not infected. Some babies have infected their mothers, through breastfeeding. Many HIV positive women have one partner, who is seronegative.

There are so many discrepancies, aside from ones relating to sexual behavior, or appearing to. Why is high HIV prevalence clustered in just a few places in most countries (Kenya is a good example)? Why are rich people more likely than poor people to be infected? Why are employed people more likely to be infected than unemployed people? What difference does religious belief system make?

What is it about location, environment, economic circumstances, employment status and other factors that results in very high HIV prevalence in some countries, but not in others? The stock response from UNAIDS tends to be about differing ‘sexual mores’, differing sexual ‘mixing’ behavior in urban and rural areas, wealth inequalities (which result in more rich people paying for sex and more poor people engaging in paid sex, apparently), etc. It’s as if sexual behavior is the only determinant of HIV exposure and status, uniquely so among diseases, a complete epidemiological anomaly, and only in (some) African countries.

Instead of concentrating on sex alone, perhaps we could examine conditions in health facilities, and differing levels of access to health facilities, differing quality in health facilities, where only those with money, insurance, even transport and good infrastructure, can access? Some people are in a better position to protect themselves from non-sexual exposure to HIV, if only they also had access to accurate health information. Health funding, insurance and access will only improve health if it is high quality and safe healthcare.

The title and overall tone of the Guardian article concludes that 'it's all about sex', before anything else appears. No argument is given for their conclusion. Asia Russell of Health GAP is right to warn that the figures are for prevalence, an indication of how many people are infected with HIV in a population or group. This is not as useful a measure as incidence, which estimates how many people were newly infected with HIV, usually in a period of one year.

But neither prevalence nor incidence figures are relevant to the content of the article because the factoids are either based on opinion, or they are commonly held assumptions (some would say ‘prejudices’). These include assumptions about 'African' sexuality, attitudes towards women, underage sex, intergenerational sex, 'promiscuity', sexual practices, 'African' masculinity, the status of women, etc.

The article is about The Guardian's and its authors' prejudices, not about Uganda, HIV or 'Africans'. Presumably it contributes to, and also concurs with, the prejudices of Guardian readers, what they expect and perhaps enjoy reading about HIV, and sexual behavior in ‘Africa’.
The article does not draw attention to the fact that the health workers (ostensibly, those purveyors of (institutionalized) stigma and discrimination) make no mention of unsafe healthcare, 'informal' or unofficial healthcare, traditional healthcare and similar practices, cosmetic practices (such as tattooing) and others that could, however inadvertently, result in exposure to HIV contaminated blood.

At the end of the article we are told that the Ugandan health ministry has called for “concerted efforts from all stakeholders for scale-up of evidence-based interventions for sustainable HIV epidemic control”. But if those ‘evidence’ based interventions refer to the same prejudices and assumptions as the Guardian article, they will have no impact on transmission rates. What’s the point in scaling up interventions that have failed?

It’s the assumptions that are wrong, not the data. Prevalence rising or falling, incidence rising or falling, female rates higher or lower than male, none of these data can tell us how people are being infected with HIV. There is data suggesting that it’s not all about sex, but this is being ignored or reinterpreted.

The racism of The Guardian has disastrous consequences for people in high HIV prevalence countries. But the realization that HIV is not all about sex can only have positive consequences: people’s exposure can be reduced, perhaps totally eliminated. Accurate health information and health education, to which everyone has a right, can achieve this. Well informed, educated patients and healthcare practitioners can take action, raise awareness and change things for the better.

allvoices

Sunday, August 27, 2017

The Deep Racism of Pathologizing Sex

What are the assumptions behind an article entitled “'Why are you having sex?': women bear brunt of Uganda's high HIV rate”? Firstly, the bulk of HIV transmission is assumed to be a result of ‘unsafe’ heterosexual behavior. Secondly, the number of infected females outnumbers males by almost 2:1, but this is blamed on ‘male sexual behavior’ (white people protecting black women from black men, etc?). Thirdly, all 'Africans' engage in massive amounts of sex. Fourthly, ‘unsafe’ sex is the rule. Fifthly, they start young...the list goes on.

This claptrap is mixed in with pseudo-science: there is no evidence that a majority of HIV transmissions in African countries are a result of ‘unsafe’ heterosexual sex, only a lot of ‘expert’ opinion; indeed, the evidence shows that the majority of transmissions are very unlikely to be a result of ‘unsafe’ sex.

Figures cited for percentages infected, males and females infected, etc, are not incorrect, that’s not why I call them pseudo-science. The sleight of hand lies in the fact that they purport to bear some relation to the levels of sexual activity that would be required for Uganda’s epidemic to be overwhelmingly a result of heterosexual activity.

More than 80,000 Ugandans were said to have been newly infected in 2015. Given estimates that suggest the risk of transmission from a male to a female for penile-vaginal sex is 1/1,250 and the risk for a female to a male is 1/2,500, those 80,000 newly infected people could represent well over 100,000,000 sex acts.

The Guardian further claims that girls between 15 and 24 years old are infected at a rate of 570 per week, reflecting a further assumption, that sexual debut tends to be at an exceptionally young age in Uganda (not true, according to most research). Most young girls have not had hundreds of sexual experiences, even girls in their 20s. Some may have, but most have not.

Most people do not have hundreds of sexual experiences every year. That’s true in every country in the world, even in countries where The Guardian would have us believe they do, countries where HIV prevalence is high. A minority of people may have a lot of sexual experiences, a small minority, according to the copious quantities of data collected by some of the best funded HIV NGOs (hundreds of surveys here).

There are two blatant non sequiturs behind articles like this: one, sexual activity is an indication of HIV prevalence, and two, HIV prevalence is an indication of levels (and perhaps types) of sexual activity. Neither of these are supported by the evidence, only by the assumptions, the prejudices, the deeply held racism of the media and the international HIV industry.

One of the most egregious consequences of these racist views is that a lot of money and effort have been expended on useless ‘abstinence only until marriage’ programs (which could be better referred to as ‘abstinence only until death’). An update to an earlier meta-analysis of such programs concluded that:

“U.S. abstinence-only-until-marriage policies and programs are not effective, violate adolescent rights, stigmatize or exclude many youth, and reinforce harmful gender stereotypes. Adolescent sexual and reproductive health promotion should be based on scientific evidence and understanding, public health principles, and human rights.”

The Guardian article is pure speculation, with a handful of figures thrown in. There is the ever-present ‘expert’ opinion about why more women than men are infected, etc, but the only constant throughout the article is racism, about ‘Africans’, their implied sexual behavior, their attitudes towards women, especially young women...the rightness of the HIV industry and the wrongness of all 'African' people.

If this sort of article is to be believed, all sex is wrong in Africa, it's all 'unsafe', it should all stop. The men are cruel, the women are powerless victims and only non-Africans can diagnose what is going on there, phrenologize the population, profile the groups, strategize their rehabilitation and save them all from damnation ('Shut up and get back in your pigeon-hole, we were right all along!').

The assumption behind this Guardian article is that HIV is almost always heterosexually transmitted in African countries, and the only way this could be true is if ‘Africans’ really are as promiscuous, impervious to reason, cruel and thoughtless to those around them and, frankly, primitive and uncivilized, as the age-old prejudice says they are. As long as it’s about ‘Africans’, you can insinuate these things as often as you want in the mainstream media.

This kind of article can give the impression that apartheid never ended in South Africa. Instead, it spread all over the world, affecting people from African countries and people of African origin. Africans are still apart when it comes to HIV, infected in numbers that are orders of magnitude higher than among non-African people. 'Explanations' of high HIV prevalence tell us that 'Africans' really are different, that non-Africans don't behave the same way when it comes to sex, that there really is something 'other' about heterosexual sex among black people. Pure racism.

allvoices

Thursday, August 24, 2017

Voice of America: Masters of Clickbait

According to an article in Voice of America “Women and girls as young as 12 from Kenya's countryside are being forced into sex work to support families affected by prolonged drought.” The title of the article calls this ‘survival sex’, a popular media trope. The article goes on to claim that the area in question here, Turkana, “suffers from Kenya's second-highest HIV infection rate”, and attributes this to the IRC (International Rescue Committee).

This popular coupling of sex and HIV, spiced up with mentions of sex tourism, underage girls and the ‘survival’ element, is ubiquitous in the media. Even specialist publications about HIV seem obsessed with sexually transmitted HIV, to the exclusion of infections through unsafe healthcare, cosmetic care and traditional practices, which can all run the risk of coming into contact with blood. This can result in transmission of viruses such as HIV, hepatitis C and various others.

Two questions arise from this VOA article alone: first, what proportion of HIV is transmitted through sex, and what proportion is transmitted through other, non-sexual routes? And second, what is the relationship between food shortages and poverty in general on the one hand, and risky sexual behavior on the other?

In answer to the first question, VOA or the IRC, whoever came up with the figure, is wrong about Turkana having the second highest HIV prevalence in Kenya. The highest prevalence figures can be found around Lake Victoria, with Homa Bay having the highest, at 26%. National prevalence is said to be 5.9%. In comparison, prevalence in Turkana is 4%, and is claimed to have halved in the past few years.

Which leads to the answer to the second question: if poverty and food shortages have been increasing in Turkana for the last few years and HIV prevalence has been dropping, that may suggest that the correlation between the two is negative. Of course, what we really need to know is whether incidence, the percentage of new infections, is increasing or decreasing (along with an indication of how all these people are being infected, of course).

The VOA article goes on to mention sex tourism, ‘survival sex’, child sex, how little money those involved make, how they are exploited and often make no money at all. It’s extraordinary how data collectors can know so much, apparently, and yet still know next to nothing about how people are being infected. Immense amounts of data are regularly collected about sexual behavior in high HIV prevalence countries, always showing that the majority of people have sex, but also showing that only a minority have a lot of sex, a lot of partners, engage in practices considered risky, etc (you’ll find hundreds of reports on the DHS website).

The article mentions another dubious figure, this time from UNICEF: “In 2008, the United Nations Children's Fund estimated that 30 percent of girls in coastal Kenya were forced into prostitution.” This makes it sound like 30% of all girls in coastal areas are forced into prostitution; the claim is probably that 30% of people working in prostitution were forced. The second version is still highly questionable, though typical of UN offices, but the first version is simply not credible.

There is no intention to dispute claims that there are food shortages, poverty, prostitution, HIV and many other severe problems in Kenya and elsewhere. But the desperate attempt to connect HIV with sex, and adding in as many shocking practices as possible to help readers swallow the claim, distracts attention from how people are being infected; it distracts attention from unsafe and insanitary conditions in healthcare facilities (and, probably to a lesser extent, from dangerous cosmetic and traditional practices).

This VOA article is disingenuous in not checking its claims against readily available data. The IRC, like all international NGOs, is anxious to increase funding, and reducing HIV transmission, poverty and food insecurity are all laudable aims. But the sloppy sensationalism in the article also leaves the impression that the claimed concerns about the dangers of ‘survival sex’, child sex tourism and child prostitution are being inflated for fundraising purposes. It also raises important doubts about what proportion of HIV is sexually transmitted.

allvoices

Tuesday, August 22, 2017

Missing the Point: Bloodborne HIV in Malawian Prisons

Journalists can never resist anything they interpret as being 'evidence' of sexual practices in prisons. For example, an article about HIV prevalence in a prison in Malawi concludes that it must all have been transmitted sexually, and rants on about homosexuality, with prurient rubbish about whether the distribution of condoms does or does not 'promote' homosexuality.

This article cites an odd finding: "A recent screening exercise conducted by the Malawi Prison Services at Chichiri Prison in the commercial city of Blantyre revealed that out of 1880 inmates tested for syphilis, 46 were diagnosed positive. The exercise also revealed that out of the 1,344 inmates screened for HIV, about 100 were diagnosed positive and 62 of them were newly infected."

That means syphilis prevalence stands at 2.5%, yet HIV prevalence stands at 7.4%. As syphilis is generally easier to transmit sexually than HIV, the fact that HIV prevalence is three times higher may suggest that much of it is not sexually transmitted.

For example, there could be some questionable practices in the prison healthcare facility, including unsafe practices among those administering first aid. There could also be traditional or prison related practices that risk bloodborne transmission of HIV, hepatitis and other conditions, such as tattoos, blood oaths, traditional medicine, etc.

There may even be illicit drugs administered in a way that risks bloodborne transmission of viruses and infections. Indeed some could argue that, since HIV prevalence in this prison is lower than prevalence nationally, which stands at 9%, perhaps there are a lot fewer risks in prisons than in the general population, sexual and non-sexual risks?

Constantly associating HIV with sexual and homosexual practices reinforces the view that HIV is always transmitted through sexual contact of some kind. As a result, people fail to take precautions against non-sexual transmission risks, of which there are many.

The article goes on to bemoan colonial-era laws prohibiting homosexuality, the evident influence of some evangelical churches, social 'conservatives' and other misanthropes. But this misses the point that it is the entire HIV industry that goes to great lengths to distract attention from non-sexually transmitted HIV, through unsafe healthcare, cosmetic and traditional practices.

allvoices

Thursday, June 15, 2017

Lisbon Declaration: Scare Stories about Sex Cost Lives

Why would women in an African country fear being diagnosed HIV positive, refuse to take part in a treatment program that would keep them alive, and probably prevent them from infecting others? After all, the virus has been around for over 30 years and treatment has been available, free of charge, for more than a decade. We know how it can be spread, we just haven't agreed on which are the most dangerous modes of transmission. But a study has found that women believe their husbands and families will reject them, perhaps divorce, disinherit, physically attack or even kill them because of their status.

Well, it's not quite clear why Measure Evaluation felt the need to ask women why they were afraid, given the role of the HIV industry in stirring up that fear. Do the researchers think anyone would like to be diagnosed HIV positive and have to go home to their partner and explain how they were infected with a virus? The HIV industry insists HIV is almost always transmitted through sexual intercourse in African countries. It's different in European countries, where people are not assumed to be 'promiscuous' just because they test positive.

HIV has long been presented as being primarily sexually transmitted among heterosexuals, in African countries. People who are infected tend to be told that they were almost certainly infected by having sexual intercourse with a HIV positive person. However, many people who have tested positive have objected that they have not had sexual intercourse at all; or they know that the person (or people) they have had sex with are negative; or they took adequate precautions, etc.

In non-African countries, such as the US, the largest group of people infected with HIV are men who have sex with men. The next largest group is injecting drug users. Therefore, many would ask why heterosexual sex appears to be so much more risky in some African countries than it does in non-African countries. Prevalence among certain groups, such as young women in parts of South Africa, has approached 50%, even higher sometimes. Prevalence is over 20% in some southern African countries (although not in any non-African country).

UNAIDS, WHO, the US Centers for Disease Control (CDC) and other parties have tied themselves in knots trying to explain away the glaring racism implied in the claim that up to 85% of infections in African countries are a result of unsafe sex. When non-African people say that they could not have been infected through sexual intercourse, the matter can be investigated. Otherwise, their own statement of their risks is accepted, and they are not branded as some kind of sexual deviant.

I'll quote Catherine Hankins, formerly a senior officer at UNAIDS, expressing her views on 'African men': "Take a middle-class African businessman. He has had five women - nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a 'deuxième bureau' - a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip."

Hankins and her fellow scientists may see this as a reasonable explanation for extraordinarily high rates of transmission, usually in relatively clearly delineated pockets, in high prevalence African countries. But if that's what 'African' men tend to be like, you might expect HIV prevalence to be relatively high in almost every 'African' country, in all cities, and in all densely populated areas. You could also be forgiven for wondering whether Hankins believes that all women are similarly 'promiscuous', or if they are mostly victims.

The reality is quite different: HIV prevalence is highest in a handful of southern African countries; next highest are parts of East African countries, such as the area around Lake Victoria and one of the southern districts in Tanzania; Nairobi, Kampala and a few others places were also hard hit by the pandemic (with low prevalence elsewhere); but in central African countries, even West Africa, prevalence is much lower, and in North Africa rates are lower than in many western countries.

In fact, prevalence is often high among wealthier people, employed people, people with access to better road infrastructure and better access to healthcare. 'Promiscuity' (perhaps not as rich as Hankins' scenario) occurs everywhere, not just in a handful of southern African countries, in cities or in diamond and gold mines. You could say it is fairly widely distributed, in Africa and elsewhere. Some people are 'promiscuous', but most are not. So unless you accept redneckery like Hankins' (which is something of an industry standard), HIV should also be much more evenly distributed, at least in African countries around where the virus seems to have emerged.

The patterns of HIV transmission suggest that there are additional modes of transmission aside from heterosexual sex. These may include unsafe healthcare, where skin piercing equipment is reused without sterilization, unsafe traditional practices that involve skin piercing, even unsafe cosmetic practices, such as ear and body piercing, tattooing, etc. But the patterns of transmission do not suggest levels of unsafe sexual behavior that would be beyond most people, in inclination, energy, even time.

So instead of asking why women are afraid to be diagnosed as HIV positive, or why 'African' men are angry (especially HIV negative ones), the international HIV community should ask how they have allowed themselves to be fooled by such tired old myths, such as those about 'African' sexuality or typical behavior of 'African' men. The HIV industry is still happy to test people and send them home, so they can tell their HIV negative husbands and partners that they have a sexually transmitted virus. They then have to persuade their family and community that they are not 'promiscuous'. If the HIV industry didn't believe them, why would their family or community?

The World Medical Association's Declaration of Lisbon on the rights of the Patient states that: "Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services. The education should include information about healthy lifestyles and about methods of prevention and early detection of illnesses. The personal responsibility of everybody for his/her own health should be stressed. Physicians have an obligation to participate actively in educational efforts." Failing to inform people adequately means they take risks they needn't take, are stigmatized because of their HIV status and are much less likely to accept treatment that keeps them alive, and reduces the risk of infecting others.

Of course people are afraid and angry, they are being told lies about HIV, about the people closest to them, and about 'Africans' and their superhuman 'promiscuity'. UNAIDS, WHO and the rest know that heterosexual sex cannot account for levels of HIV in certain areas in Africa. So no more lies about concurrency, 'traditional' sexual practices, predominant 'mores', migratory patterns and the like. HIV can be transmitted through heterosexual sex, but it is much more easily spread through unsafe healthcare and other bloodborne modes of transmission. If people are not informed, they will continue to avoid diagnoses, life saving drug programs and anything else to do with HIV.


allvoices

Sunday, June 4, 2017

From Barefoot Doctors to Barefaced Bankers

The Oakland Institute researches and publishes about access to some of the most basic of human needs that continue to be denied to the majority of people in developing countries. These issues include land, food security and sovereignty, trade and aid. An exceptionally powerful barrier to access to these and other human needs is the World Bank and its associated institutions.
A recent report details how the WB's 'private sector arm' (or is the WB merely a public sector tool of the private sector?), the International Finance Corporation, is deeply involved in extensive land grabbing projects, particularly in some of the most impoverished countries in Africa. There's a brief article about the report, and other WB related reports, on Oakland's site.
These landgrabs are carried out purely for profit, although descriptions of them are often padded out with talk of 'sustainable development' and other honeyed words. Far from benefiting anyone in poor countries, these programs squeeze massive profits from the poor through exploitation of the land for palm oil and other damaging commodities.
The few ecologies that have survived decades of colonialism and neocolonialism continue to be destroyed by institutions that claim to be 'helping' the poor. Populations in the countries affected become more dependent, less food secure and less healthy, communities and government, local and national, become less stable.
The current president of the World Bank, Dr Jim Yong Kim, used to be a 'global health leader', co-founder of Partners in Health, holding senior positions in some of the biggest names in US educational institutions (albeit some of the most neoliberal and elitist ones).
He held a senior position in the World Health Organization, contradictory as that sounds for someone who used to champion the work of Barefoot Doctors, 'accompaniment' and other types of community health volunteer. Indeed, it was his associations with work with the very poor that were used as arguments for his appointment to the WHO and, eventually, the World Bank.
It's decades since the World Bank has even pretended to have anything to do with the world's poor. It has long prioritized the ambitions of rich countries to grab land, control food production, kill off any grassroots movements, destabilize governments that their rich country management don't like and generally promote the status quo: more for those who are already rich and powerful, never mind the exploited.
But organizations like Partners in Health have been elevated to almost cult status by the press, in papers and books and in the popular imagination. Their talk of 'liberation theology' (to those who have will be given more?) and frequent mentions of touchy-feely philosophers such as Michel Foucault and Paulo Freire attracts those who like a veneer of 'ideology' with their neoimperialism. Another founder of Partners in Health, Paul Farmer, has even been referred to as 'a saint' by Kim.
Perhaps this association with (currently fashionable) cultist tendencies and cult figures have been factors in Kim's rise to president of one of the most destructive institutions in the history of rich countries' savage profiteering in poor countries? It is very hard to find criticizm of people like Kim and Farmer, which is part of the reason for suggesting an element of cultism, of cult status.
However, there is some criticizm of Kim, given his prominence in fields beyond medicine and development. One critic even argues that Kim twisted the philosophies of several philosophers to put forward what is just a barefaced, market driven, neoliberal agenda, that he manages to sell to his adoring followers. The World Bank seem to have recognized Kim as a fellow traveler a long time ago.
There is also a powerful critique of Farmer, which adds to the impression that these guys have done very well under the status quo (thank you very much), have done everything in their power to 'fight' for the status quo and have become leading figures in promoting a kind of chocolate box version of activism, that you can buy and distribute among your friends on your way to the latest popular protest.
Apparently Kim was fond of urging students to study for MBAs rather than the medicine (and anthropology, don't forget, that's where the ideology gets a toe in the door) that he and Farmer studied. One critical account of Farmer suggests that "Farmer and Kim are...embodiments of the dark side of the spirit of 1968". Others question the wisdom of Kim urging for action without theory, especially those who have studied Marx and Freire.
Using polite terminology such as 'structural violence', rather than condemning anti-poor policies wielded by the World Bank, neither will question the actions of international development institutions, or the rich country governments who profit from poverty and inequality. So neither of them are likely to have the stomach to criticize an institution that played such a shameful role in destroying any opportunity African countries had to develop themselves in the decades following independence.
Depending on how you view him, Kim appears to have come a long way from his early work in bringing healthcare to the poor. But he also showed great foresight and diplomacy in his treatment of what has become one of the principal causes of poverty, the World Bank. So who knows, perhaps he always had a penchant for banking? He and Farmer like to warn against what they term 'immodest claims of causality'. But Freire reminds us that impeding those who would question the likes of the World Bank are themselves committing structural violence.

allvoices

Wednesday, March 22, 2017

Drugs for All Deemed More Profitable than Circumcision

Demands to roll out mass male circumcision programs, claimed to reduce HIV transmission, date back at least 20 years. Other claims about the 'benefits' of circumcision go back centuries. But by the time the programs had started several other interventions had been identified that have a far better claim to reduce HIV transmission.
For example, 'test and treat', the practice of putting everyone who tests positive for HIV on ARVs immediately, is claimed to reduce transmission to a HIV negative sexual partner by 96% or higher. (Note, 90 is something of a magic number in UNAIDSland at the moment, with their 90-90-90 strategy replacing various other magic numbers conjured up in the past.)
If the number of HIV positive people in the world is something around 30 million, depending on which estimates you use, and about half of them are claimed to be on ARVs already, there are still around 15 million who can benefit from ARVs. That's worth, say, a few billion dollars.
Although a lot of those opposed to mass male circumcision don't seem to realize this, many of those promoting circumcision are the same people who promoted behavior based programs, particularly those with an emphasis on 'abstinence'. Those programs, although they never completely died out, were a disaster. Even the people formerly pushing them now admit that they probably had no impact on HIV transmission. But they wanted to find another source of funding to replace the vast amounts that used to go into 'prevention', a lot of which was spent on behavior based rubbish.
Circumcision seemed like the answer because the number of people who could be targeted for circumcision could run into hundreds of millions. Every year millions more male children would be available to keep the programs profitable.
At first the promoters claimed they were only targeting sexually active adults, but they quickly found that most of them didn't want to be circumcised. It was much easier to recruit children and now they can turn their attention to infants.
But with test and treat, coupled with PrEP, how can the circumcision enthusiasts still claim that there is any benefit to the operation? They need to target almost the entire male population in countries where circumcision is not widely practiced. They must carry out the operation on about 75 men for every one claimed reduction in HIV transmission.
The other interventions, test and treat and PrEP, are claimed to be targeted at those most at risk. Let's take a look at who is thought to be most at risk, and see just how many hundreds of millions of people that involves, who would need to be taking these drugs for the rest of their lives in the case of test and treat, and for as long as they are thought to be at risk for PrEP.
In western countries there are few groups who are thought to be at risk. The biggest group is men who have sex with men. The second biggest group is injecting drug users. But aside from commercial sex workers, who are given some choice in prevention options in many rich countries, there are not many others.
The picture is completely different in southern and eastern African countries, with high prevalence and/or large numbers of people infected with HIV. This article about a PrEP program in Kenya says the groups of people claimed to face the highest risk of being infected include:
  1. Discordant couples (where one partner is HIV positive and one is HIV negative)
  2. People who frequently contract sexually transmitted infections
  3. People who are said to be unable to 'negotiate' condom use
  4. People who frequently use post-exposure prophylaxis (a short course of ARVs for people who suspect they may have been infected, taken within 72 hours of contact)
  5. People who share injecting equipment
Out of the estimated 77,600 new infections in Kenya it is not clear how many arose among any of the listed 'risk' groups. High prevalence countries tend not to trace contacts, assuming that the bulk of transmissions (about 90% if you exclude infants said to have been infected by their mothers) were a result of heterosexual intercourse.
You could easily add other risks to the above list, for example (most of the following are a risk in developing countries although 7, 10 and 12 are likely to be more common in rich countries):
  1. People who have given birth in a health center/clinic
  2. People who have given birth at home, or anywhere other than in a health center/clinic
  3. People who have received birth control injections
  4. People who have had injections, blood tests, transfusions, dental care, infusions, etc
  5. People who have had operations that involved piercing the skin, major or minor (including circumcision)
  6. People who have received some forms of traditional healthcare that involved skin piercing
  7. People who use injected appearance or performance enhancers (eg botox, steroids, etc)
  8. People who get their head shaved or where skin is pierced and/or weakened by processes
  9. People who receive manicures, pedicures, etc
  10. People who have body piercings
  11. People who practice scarification and other practices
  12. People who get tattoos
Of course, with the second list, you could warn people about the risks and clean up health centers, cosmetic establishments and anywhere skin piercing occurs (the list is surprisingly long). This would seem preferable to putting almost everyone in a population on expensive drugs for many years.
But UNAIDS, CDC, WHO and other establishments object to calls to warn people about the risks they face in health and cosmetic facilities in developing countries. They warn some people from rich countries about the risks in poor countries but they refuse to warn people in poor countries.
Even concentrating on the risks listed in the Kenya article it is easy to identify many millions of people who could be said to need the $775 per annum PrEP, which is the estimated cost of the drugs alone (I don't know what other costs there may be).
So you can see the attraction for the HIV industry. If there were only 5 million people requiring years of ARVs, for some, a lifetime of ARVs, that's several billion dollars for Kenya alone. There are countries with higher prevalence and others with higher numbers of people infected than Kenya.
With only a few billion dollars for mass male circumcision, with its 1.3% absolute risk reduction, or even the claimed 60% relative risk reduction, drugs for the sick and the well seems like a far more lucrative strategy. Even if the benefits realized for mass male circumcision far exceed those unlikely claims, they can't come close to the claimed benefits of test and treat and those of PrEP.
One problem is that you can't roll out PrEP for many of the groups claimed to benefit. For example, in discordant couples the positive partner should already be receiving ARVs. People who share injecting equipment could be better served by a clean syringe and needle program. There may be other examples, where overlapping PrEP and test and treat might raise eyebrows among the more scrupulous in the industry.
And it would be perverse to give PrEP to people while they still attend clinics and other places where skin piercing procedures take place without warning them about the risks and also ensuring that those places start to abide by strict infection control regulations that people in rich countries (and rich people in poor countries) enjoy.
If PrEP and test and treat strategies work as well as we are told, let's hope they do as well in the field as they did in trials. But let's also get rid of these silly mass male circumcision programs. We no longer have to pretend that they will reduce HIV transmission, or even pretend that that's why they were rolled out in the first place. Worse still, the profits are orders of magnitude lower than the drug based strategies.

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Wednesday, March 15, 2017

HIV: Cuba's Success and Uganda's Failure

Uganda is frequently mentioned in glowing terms in articles about HIV, especially in relation to the late 80s, 90s and early on in the 2000s. In contrast, Cuba is rarely mentioned in glowing terms, although the percentage of 15-49 year olds infected with HIV (prevalence), at 0.3%, is 23 times smaller than the same figure for Uganda, which stood at 7.1% in 2015 (all HIV figures from UNAIDS).
In fact, one could suggest that Uganda never got to grips with the epidemic. They still can't explain why so many people, said to face a low risk of being infected with HIV, have seroconverted over the past several decades. Despite huge amounts of research, money and other resources being thrown at the country, the bulk of published research on HIV in Uganda seems to be focused on assumed sexual behavior and assumed sexually transmitted HIV.
Little or no international funding went into the HIV epidemic in Cuba. The country worked hard to research the epidemic, even before the first HIV positive person was identified there, several years before. Luckily, the country had a well developed health service, with more doctors per patient than any other high prevalence country (including the US). Indeed, the US (where an estimated 1.2 million were living with HIV in 2013) seemed intent on ridiculing Cuba's approach to the virus.
Some of the criticisms were directed at claimed human rights aspects of Cuba's achievements. It was often stated or implied that men who have sex with men were especially targeted by, for example, Cuba's imposed 'quarantine'. The quarantining started when little was known about the course of the illness, but it was relaxed once more was known. A number of personal accounts, some from men who have sex with men, now make it clear that many of the people quarantined are grateful to have received the care they got at the 'sanitaria' (there are links to other similar articles from this article).
An article by Tim Anderson finds that the quarantine did not target men who have sex with men; it also finds that other procedures were carried out in accordance with international guidelines. Anderson notes that Cuba was 'more thorough' in their testing and tracing procedures. Cuba has continued to make improvements in how they deal with the epidemic, which is a low level one, with men who have sex with men being the most affected group.
Sarah Z Hoffman refers to Cuba's HIV program as 'the most successful in the world'. Cuba approached HIV with the aim of reducing the likelihood of those infected going on to infect other people. That may sound like an obvious aim, but the greater thoroughness of Cuba identified by Anderson can be contrasted with a reduction in contact tracing in many countries, where it was claimed that certain groups were being unfairly targeted by such measures.
Cuba also started providing all HIV positive people with antiretrovirals in 2001, which they produced themselves as generic versions. Other countries had to wait a long time before they could provide more than a small fraction of HIV positive people with ARVs, and they had to pay astronomical amounts of money for them for years (although the costs are far lower now).
Hoffman writes "HIV infected people must provide the names of all sexual partners in the past six months, and those individuals must be tested for HIV. People found to have any sexually transmitted disease must undergo an HIV test as well. Voluntary HIV screening is encouraged."
This is one of the places where practices in Cuba differ from practices in most other countries. This is called 'contact tracing' and it's a vital tool of infection control. But in most countries people can claim anything they wish to about their sexual partners, that they have never had sex, that they have only engaged in heterosexual sex, that they have never injected drugs, etc. If people can withhold such information then contact tracing is impossible.
(My previous post is about a rare and valuable contribution to the history of HIV in Africa from John Potterat’s book ‘Seeking the Positives’, much of which concentrates on his work on HIV and STI epidemiology in the US. There’s a link to the chapter here. The approach the US adopted towards HIV could hardly have been more different from that of Cuba. Unfortunately, most other countries, certainly most poor countries, wedded themselves to the US, till death…etc.)
As a result of not tracing contacts, or of not doing so very assiduously, countries like the US, with extremely high transmission rates in certain groups, have never got their epidemic under control. In common with Cuba, the largest proportion of new HIV infections now is among men who have sex with men. Unlike Cuba, there is also a large injecting drug population in the US. But where contacts are not traced, they can not be offered the same opportunity to avoid infection if they are negative, or avoid infecting others if they are positive. Nor can they be 'connected to care' as quickly as possible.
In fact, many of the things western countries write copiously about, such as early testing and treatment, universal testing, elimination of mother to child transmission, universal access to treatment, were achieved in Cuba years ago, but have never been fully achieved even in some western countries. Where HIV prevalence is highest, in southern and eastern African countries, some of those achievements may not be realized in our lifetime.
Unfortunately for the worst affected countries, the rights of individuals are claimed to be foremost. Their contacts, past and future, are not treated as individuals. If the individual has multiple partners and chooses not to reveal that they engage in high risk practices, that’s considered to be the individual’s business. If the individual has had no sexual partners, or no HIV positive sexual partners, then the source of their infection needs to be identified. But in high prevalence African countries tracing of non-sexual contacts is rare. What you do find a lot of in research is findings referred to as ‘biased’, because the researcher expected every HIV transmission to be a case of sexual transmission.
(Despite the apparent desire of most countries to protect people's individual rights in relation to HIV, this approach seemed to go out the window when the virus involved was ebola. Some 'infection control' measures seemed to involve groups breaking into people's houses, forcing them into shabby health facilities, burning their property in public, spraying their houses, breaking up families and communities, etc. Who knows what approach will be taken to the next headline grabbing epidemic.)
So why all the attention and resources for a country that appears to have lost control of HIV a long time ago, and why all the rhetorical questions about Uganda, how their 'success' can be replicated, etc? More importantly, why so little attention for Cuba, and why is it so belated? We can learn a lot from both countries. Instead, we should be asking what Cuba did right, and continues to do right, but what Uganda did wrong, and continues to do wrong.
Cuba's approach to HIV may have been the most successful anywhere. Some would go further and claim that Cuba may be the only country that was seriously threatened by the virus, but gained complete control over the epidemic early on, and retained that control. In the sphere of human rights, also, Cuba has made a lot of progress. Uganda, on the other hand, continues to move in the opposite direction in the fields of public health, human rights, HIV, political stability, economy, etc.

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