HIV in Kenya

Circumcision: Non-Paternalistic Public Health is Possible in Africa, Isn't It?

noreply@blogger.com (Simon) — Sat, 11 Feb 2012 16:38:00 +0000

After holding out for a while, apparently the Malawian government has now had a change of heart about male circumcision and has caved in to pressure from the international HIV industry to include the operation in its HIV 'prevention' strategy. There were good reasons for holding out: prevalence is a lot higher in the Southern part of the country, where almost everyone is already circumcised. While the headline figure is 'up to 60% less likely to be infected', there are many countries where men are more likely to be infected if they are circumcised, aside from Malawi (see table of HIV infections in circumcised and intact men).

The country claims to have circumcised 5,000 men already but they plan to circumcise another 245,000 by 2015, despite the conflicting evidence about the effectiveness of the program. It is also revealed that only 4% of the country's medical staff have been trained to carry out the procedure. That's extremely worrying in a country where there is such a shortage of medical staff, regardless of what they know about circumcision. Other research in Malawi has shown that living close to a health facility is a serious risk factor for being HIV positive. But I don't expect that to be mentioned in the evangelical literature.

The last sentence in the article is particularly badly phrased: "people still had to be reminded that male circumcision alone is not 100 percent safe". The sentence aims to express the idea that male circumcision on its own will not protect against HIV and the 'up to 60% protection' requires the use of condoms (which is why some people ask if the circumcision is even necessary). But sadly for Malawi, figures suggest that HIV prevalence is far lower among both males and females who never use condoms than among those who ever use them.

Another reason why the sentence is unfortunately phrased is that it sounds like it means the operation itself may carry risks which, ironically, is true. In addition to many unexpected HIV infections in male and female virgins, where prevalence was similar to or higher than that among non-virgins, there have also been questions raised about mass male circumcision programs, where some of those circumcised might have been infected as a result of the operation itself. In countries where health facilities are in such bad condition that they may carry as high or even higher a risk of HIV infection, mass male circumcision sounds like an extremely dangerous HIV prevention strategy, particularly in Malawi.

Meanwhile, Uganda claims to have already circumcised 600,000 men since 2009. Uganda has had quite a few probable healthcare associated HIV outbreaks, including during the Rakai circumcision trial, which is supposed to show that circumcision is a viable strategy for HIV reduction. There, the aim is to circumcise 4 million men, until HIV prevalence "reaches zero", which will be a very long time from now at the rate things are going. Notably, despite evidence for healthcare associated HIV transmission in Uganda, the ridiculous claim about 80% of transmission being through heterosexual contacts is still being made (and elsewhere it is claimed that almost 20% more is from mother to child transmission).

The article also claims that 768,000 men have been circumcised in Tanzania, against a target of 1.3 million. Strangely, it is also claimed that Kenya has only circumcised 76,000 men against a target of 860,000 men by 2011. Other claims have put the figure in the hundreds of thousands, against a far higher target, and that was just among the Luo tribe of Nyanza province, a few million people. Another country where circumcised men are more likely to be infected than uncircumcised men is Rwanda, and it is stated that they have already operated on 415,000 men, out of a target of 900,000.

Paternalism behind African 'public health' programs funded by Western countries is questionable enough, but can't these circumcision evangelists at least wait until the more dubious arguments been re-examined and until there is stable and convincing evidence for carrying out what is probably an unnecessary and clearly an unsafe operation on more than 20 million people? Jacques Pepin (in The Origins of AIDS) has shown the sort of damage that resulted from public health programs carried out in colonial days (motivated by a desire to maximize profits); we now know far better than to carry out mass male circumcision programs, but it seems we're still going ahead with them anyway.

[For some of the less well publicized details about the three circumcision trials used to advocate for mass male circumcision, see the Don't Get Stuck With HIV website and blog.]

Gates to Unleash Destructive Agricultural Technology on Unsuspecting Tanzanians

noreply@blogger.com (Simon) — Wed, 08 Feb 2012 17:56:00 +0000

An article in The Citizen opens with the statement: "Tanzania will not make significant gains in its endeavours to eradicate poverty through increased agricultural productivity if the doors to Genetically Modified Organisms (GMOs) are not opened." It seems he was quoting the minister of agriculture, who is a professor of some kind, but is also quite uncertain about the population of Tanzania.

The minister wishes for "more efficient use of resources, enhanced food production and higher farm incomes" and other nice things. He notes that three quarters of the working population are only contributing to 27% of the gross domestic product and says that low productivity is associated with poor agronomic practices and limited use of improved seed, fertilisers as well as lack of sustainable control of pests and diseases".

But Justin Sandefur of the Center for Global Development takes quite a different view. He criticizes the Bill Gates annual letter for what the man has to say about research that his Foundation is funding in Tanzania, probably the same research the above minister is welcoming, certainly a similar kind of research. Sandefur is entitled to have a view on this as he carried out some agricultural research funded by the Foundation in Tanzania. Perhaps I was wrong in suggesting that Gates doesn't have advisers who have the balls to stand up to him; perhaps he just doesn't listen to them.

Gates' optimism about innovation being enough to lift Tanzanian farmers out of poverty is contrasted with the fact that people leaving agriculture altogether has been the main source of poverty reduction. Sandefur finds that innovation is not very popular and most farmers don't use modern farming technologies. And as income levels in agriculture are much lower than those outside of agriculture, leaving agriculture is probably the best way of reducing poverty levels. This has been a trend for some time, apparently.

Sadly, Sandefur doesn't have much to say about the kind of technology Gates is particularly interested in, GMOs. These were not developed with lifting Tanzanians, or anyone else, out of poverty in mind. They were designed so those who controlled them would also control the people who grow them and the land and water where they are grown. Those who produce the GMOs also produce the agricultural technologies. That's what Gates is attracted by; I don't understand why he keeps mentioning poverty and the like but I assume it's a form of spin.

Sandefur also takes Gates up on his use of the terms 'population bomb' and 'global food supply shortages'. But Gates and his views on population are infamous; he thinks there are too many people in the world; especially poor people, whom he believes should have fewer children. But as his flunkies should be able to tell him, local food shortages are not due to a lack of food. It's just that poor people can't afford it, especially if it's being grown for export, by foreigners, for a big profit, on land that has been taken from small farmers.

I agree with Sandefur that there are limits to technological fixes but not that Gates should continue with what he is doing. GMOs are destructive to the food supply, to food security, to the economy and to the environment. Other Gates technological fixes, such as in health, can also be destructive. If more people leave agriculture, that may improve conditions for GMOs to take over, as they need very large amounts of land, a lot of technology and very few employees. But this doesn't improve the prospects of those leaving agriculture, nor does it address the problems of poverty and underdevelopment for Tanzanians as a whole. People who are poor and whose income is stagnating will only become less and less able to afford what they need to survive.

Gates doesn't have a plan for all those who stand to lose out under his proposed GMO technocracy, which is all Tanzanians, whether they work in agriculture or not. But non-GMO agriculture is in a far better position to increase food supply, ensure food sovereignty, improve nutrition, protect the environment and provide various advantages without compromising the current, very weak economy. The minister of agriculture may not wish to turn down Gates' philanthrophy but there's a good reason why Gates wants to do things in Tanzania and it has nothing to do with improving the lives of Tanzanians.

For more about GM and non-GM crops, see GMWatch.

Another Look At Sexual (and Non-Sexual?) HIV Risk

noreply@blogger.com (Simon) — Tue, 07 Feb 2012 18:46:00 +0000

A recently published article finds that, out of 1834 African participants who belong to various groups thought to face high risk of being infected with HIV, incidence (the rate of new infections per year) was highest among men who had sex with men (MSM). In Western countries, MSM often have the highest rates of HIV transmission, followed by intravenous drug users (IDU). But because such a huge proportion of transmission in African countries occurs among heterosexuals who don't fall into any of the above risk groups, MSM generally account for a relatively small percentage of those infected with HIV there, as do IDUs.

It was also found that "[p]aying for sex was inversely associated with HIV infection". In Western countries, sex workers are not especially likely to be infected unless they are also IDUs. But in African countries extraordinary prevalence rates have been reported for this group, even where they are not reported to have other risks. Prevalence rates of 70 or 80% have been reported, prompting some to wonder if the women might have faced one or more non-sexual risk not examined by those doing the reporting. The alarmingly high rates reported in the 1980s and 1990s dropped rapidly, often long before the country involved made any attempts to reduce infection rates; but it's good to hear that the risks this group faces may be receding.

The study aimed to identify risk populations for HIV prevention trials. If those taking part in the trial do not face much risk it will be difficult for a trial to show an effect. But the results should also be of interest to those whose job consists of making claims such as the one about 80-90% of HIV transmission in African countries resulting from heterosexual sex. Where HIV appears to be transmitted rapidly and heterosexual sex is found to be the only significant risk, there is then a problem of explaining what is so risky about heterosexual sex between Africans, something that has eluded those working in the field so far. Some of the elusiveness may stem from the fact that heterosexual sex was assumed, rather than found to be the only risk.

One of the most surprising findings was that no HIV infections were found in over 300 women in Nairobi who identified themselves as sex workers. The authors speculate that this may be due to condom use, fewer HIV positive clients, more clients on antiretroviral drugs, etc. But hopefully the finding will prompt some reanalysis of some of the eyewatering claims made about numbers of clients per day and other speculation about unsafe sex mentioned (ad nauseum) in the past. Much of it seemed to be created to fit the rates of HIV infection found rather than to investigate if such behavior really existed or if it was common enough in high HIV prevalence areas to explain transmission rates; little effort seems to have been made to establish if sex workers faced other, non-sexual HIV risks.

The finding that pregnancy rates were higher than expected may suggest that women, even sex workers, were not using condoms particularly consistently. Extremely high rates of sexually transmitted infections in one area, and fairly high in the others, also suggest that condom use campaigns may not yet have had much impact among some high risk groups (and those thought to be high risk). If the inverse association between paying for sex and HIV prevalence among MSM is an indication that condom campaigns can work when properly targeted, that is certainly an important finding, as is the one that MSM perceive anal sex with men to be lower risk than sex with women. But some well publicized claims about female sexual behavior may have supported that perception.

One of the worrying things about this paper is that the participants are drawn from groups thought to be at high risk. However, the bulk of HIV transmission in countries where modes of transmission studies have been carried out occurs among groups of people who are not thought to be at high risk. In other words, this research excludes most of the HIV positive population in countries like Uganda and Kenya, where relatively low risk sex is said to account for over 60% of the total.

Finally, my attention has been drawn to the appendix, which I am currently unable to access, which shows that those who have received an injection in the last three months are nearly five times more likely to be infected with HIV. Those involved in clinical trials would appear to have very good reason to start looking more closely at non-sexual risks.

Turning Off the Tap: Don't Forget, There Are Two of Them

noreply@blogger.com (Simon) — Sun, 05 Feb 2012 09:57:00 +0000

There's an article published by Peter Piot in 1987 that has had a lot of influence on the way many others have written about HIV ever since. I'd like to say it has had influence on the way people have thought, but this article seems to have been a serious obstacle to thought. Concentrating on what it has to say about women, here's how it goes: "Among 446 sera from prostitutes in Nairobi, the prevalence of antibody to human immunodeficiency virus (HIV) rose from 4% in 1981 to 61% in 1985." Also "Among pregnant women, 2.0% were seropositive in 1985 versus none of 111 in 1981."

This article and the numerous articles like it support the 'behavioral paradigm', the view that almost all HIV transmission in African countries (but not in non-African countries) is heterosexually transmitted. Why did this become the dominant paradigm and remain so to this day, despite clear evidence that it was wrong, in addition to being deeply prejudiced and stigmatizing? Well, it was concluded from the fact that "Seropositive [ie, HIV positive] prostitutes and women with sexually transmitted diseases (STDs) tended to have more sex partners and had a higher prevalence of gonorrhoea, and in women with STDs, significantly more seropositive women practiced prostitution."

Before concluding that the last statement proves, or even supports the behavioral paradigm, consider this: if someone is found to be HIV positive, it is necessary to look carefully at both sexual and non-sexual risks before concluding that they were infected sexually. while it is indeed fairly clear that people have most probably been engaging in unsafe sex if they have one or more STD, and many commercial sex workers do engage in unsafe sex, this does not mean they never face non-sexual risks. The very same sentence that identifies the sexual risks also identifies the non-sexual risks: they were probably treated for and/or vaccinated against STDs at some time in their lives, perhaps many times in their lives.

Long before HIV was recognized, sex workers were routinely rounded up for sexual health programs. In fact, the very blood samples collected in 1981 pre-date the discovery of HIV. The blood was taken at a time when injecting equipment was often reused without sterilization to an extent that has rarely been investigated. Every one of the women participating in the program faced a whole host of non-sexual HIV risks. In all probability, sex workers all over the world continue to face serious risks of being infected with HIV and other bloodborne diseases, though the risk may no longer be so high, even in African countries.

The authors can not show that the women involved were infected sexually. They wouldn't have been able to demonstrate it then and it would still be difficult to do so now. Nor can they rule out the possibility that many, if not all, were infected through the STD programs during which the blood samples were collected. But they have good reason to suspect that they are quite wrong in their conclusion about this massive rate of heterosexual transmission. And there are many other articles like this one with these exact same flaws. There is only one way that HIV prevalence can go from 4% to 61% in the space of a few years and that is through unsafe healthcare, especially that received in STD clinics.

There's a lot more that could be said about this article but let's shoot forward to the present, where the standard of analysis set by Piot and colleagues is still being rigorously maintained. As I mentioned in my last post, PEPFAR held a consultation on what they called 'mixed' HIV epidemics, those where HIV prevalence is high among those thought to be most at risk of being infected and also high among the general population, those thought (if thought is involved) to be at low or even zero risk of being infected. Remarks about Kenya's epidemic presented during this consultation show just how persistent an obstacle to thought Piot's article is.

Despite three decades of hollering about risky sex (and keeping quiet about risky healthcare), the committee accepts that 44% of HIV in Kenya is actually transmitted through heterosexual sex among couples in long term partnerships, married or otherwise; low risk sex is, according to their figures, the most risky sex of all. After low risk sex comes slightly higher risk sex, accounting for over 20% of all transmission, that between casual partners, where there is no indication that either partner is a commercial sex worker or visits commercial sex workers.

The entire contribution assumed to come from sex workers and their clients is only 14%. Note, it is no more certain that those falling into this group were infected sexually than those found to be infected in Piot's research. Sex workers and their clients, since they may often have STDs, face significant non-sexual HIV risks. But like the general population of African countries, it is mainly African sex workers who face very high HIV risks. In other countries, sex workers are unlikely to be infected with HIV unless they are also intravenous drug users. Sexual practices in some parts of some African countries may, as claimed by the HIV industry, be risky, but so are healthcare practices.

Another 15% of Kenya's HIV epidemic is said to come from men who have sex with men and prisoners. This is very ambiguous. While there may or may not be a lot of male to male sex in prisons, and anal sex is very risks, whether homosexual or heterosexual, there are also elevated non-sexual risks in prisons. Men tattoo themselves and each other, using makeshift equipment and dyes, they may take blood oaths, engage in various traditional practices, including medicine, that involves bloodletting, even take various drugs. What proportion of HIV in prisons is non-sexually transmitted?

Having inflated the figures for sexual transmission of HIV in the 'high risk' groups and claimed that low risk sex is also high risk sex, these experts conclude that all that's left for health facility related HIV transmission is 2.52%. of course, if you start off believing that 80 or 90% of HIV is transmitted through heterosexual sex, then healthcare transmission will only account for a small amount; but that's just arguing in a circle. The approximately 95% of HIV transmission that is said to be sexual needs to be re-examined. Have those producing these figures shown that all, or even most of that 95% was sexually transmitted? or, to put it another way, can they rule out non-sexual transmission in all those groups?

They are not even asking the questions. As I say above, there is an obstacle to thought here, in the form of the behavioral paradigm. Those who hold the paradigm seem unable to go beyond it. The very questions Piot should have been asking in 1987 remain unasked by most academics publishing in the field of HIV today. Papers like this one by Piot have amply fuelled prejudices ranging from those aimed at Africans and women to those aimed at men who have sex with men, drug users, prisoners, migrants, long distance drivers, religious denominations, tribal groups, nationals of various countries and others too numerous to mention.

How do we know that most people said to have been infected with HIV through heterosexual sex were really infected through sex? We don't. How can we rule out non-sexual transmission in 95% of Kenya's HIV positive people? We can't. What is the relative contribution of non-sexually transmitted HIV, such as through unsafe healthcare? We have no idea. The HIV industry likes to use the metaphor of 'closing the tap', preventing new infections; they need to see that there are two taps and both need to be closed, regardless of which one contributes most to the pandemic.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]

PEPFAR Committee Pulls Rug Out From Under Its Own Feet

noreply@blogger.com (Simon) — Fri, 03 Feb 2012 17:25:00 +0000

About a year ago PEPFAR carried out a technical consultation on 'mixed' HIV epidemics. These describe country epidemics where HIV prevalence is relatively high in the general population (compared to non-African countries), and high or very high among members of groups known globally to be most at risk, such as men who have sex with men and intravenous drug users. The consultation involved representatives from 12 countries but I'll just look at one right now, Ethiopia.

To make things clearer, in every country with a HIV epidemic, in every continent, HIV prevalence is found in high risk groups, such as the ones mentioned above. But it is only in some countries in sub-Saharan Africa that HIV prevalence is high or very high outside of these groups. In fact, in most countries in the world, HIV is rare outside of high-risk groups. And it is only in some countries that HIV prevalence is inordinately high among commercial sex workers, most of them in Africa.

So all countries with a serious HIV epidemic could be called 'mixed', whether HIV prevalence is high or low in the general population, that is, outside of high-risk groups. The problem of explaining why a virus that is difficult to transmit through heterosexual sex appears to be high among people who only engage in heterosexual sex is as perplexing for the highest prevalence countries, such as Swaziland, Botswana, Zimbabwe and South Africa, as it is for Ethiopia, Kenya, Uganda or Tanzania, where prevalence is a lot lower.

HIV prevalence in Ethiopia, at 2.4%, is far lower than in countries such as Kenya, Uganda or Tanzania, where it currently hovers at around 6%. But given the huge population of Ethiopia there could be almost as many people living with HIV there as in each of the other three countries. An estimated 137,000 people become newly infected with HIV every year. According to PEPFAR, 87% of these new infections are transmitted through heterosexual sex, with another 10% transmitted from mother to child.

This leaves a mere 3% for other modes of transmission, whether they be through men having sex with men, intravenous drug use or unsafe healthcare (something PEPFAR people tend not to mention). There are three women infected for every two men and, while prevalence is less than 1% in rural areas it is nearly 8% in urban areas. The vast majority of people, over 80%, live in rural areas and there a lot more males than females living in urban areas.

The consultation identified several 'risks' for HIV, including multiple, concurrent partnerships, inconsistent use of condoms, transactional or commercial sex, intergenerational sex (between older men and younger women), early initiation of sex for females, high prevalence of sexually transmitted infections, etc. At least, these are thought to be risks for sexual transmission. Injecting drug use and men having sex with men are said to be 'emerging' in Ethiopia.

But it's interesting to compare those 'risks' with the 2005 Demographic and Health Survey for Ethiopia. This survey suggests that there are some non-sexual risks that should be examined, especially among women who received "Birth and delivery care by [a] professional", where HIV prevalence is 9.9%, compared to only 1.2% for those who did not receive care by a professional and 2% for those who had not given birth in the last three years. HIV prevalence was 3.5% among those receiving ante-natal care, compared to 1% among those not receiving care and 2% among those who hadn't given birth in the last three years.

With some of the figures, it might be wondered which men are infecting women. Among women who have had 'higher risk' sex in the past year, HIV prevalence is 12.3%, but among men it is only 1.8%. And one of those figures that should be disturbing to condom manufacturers is that prevalence is 20% among women who have used condoms compared to 2% among women who have never used them. Prevalence among uncircumcised men is only 1.1%, compared to .9% among circumcised men, hardly a massive difference.

As is commonly found in such surveys, women in the wealthiest quintile and those with the highest levels of education are significantly more likely to be infected. In fact, the bulk of infections among women, which consititute the bulk of heterosexual infections, are among wealthier, better educated women. Wealthier and better educated men are also far more likely to be infected than poor and less well educated men.

As UNAIDS say, 'know your epidemic, know your response'. So should Ethiopeans reduce education and poverty reduction programs? Should fewer women attend ante-natal or post natal care? Perhaps they should avoid cities, where most health facilities are? Should health facilities be extended out to the rural areas, or would that increase the risk that women in rural areas face? One certainly wouldn't expect condoms to increase HIV risk among those engaging in heterosexual intercourse.

The data clearly show that HIV risk is not closely correlated with sexual practices. On the contrary, it is correlated with non-sexual risks, such as post and ante-natal care. Many of the vulnerabilities PEPFAR identify are not vulnerabilities to HIV; FGM (which is actually generally correlated with low HIV prevalence) is far more common in rural areas, where HIV prevalence is very low; poverty is clearly correlated with low HIV prevalence; early and intergenerational marriage is also more common in rural areas. There may be some true sexual risks, but the 87% for heterosexual transmission mentioned above can be no more than a delusion.

Before escalating their usual response, which is to assume that almost all transmission is heterosexual despite evidence to the contrary, PEPFAR should remember how closely HIV tends to cluster around main roads, close to rural centers and, crucially, close to health facilities. HIV prevalence is not evenly distributed throughout countries like Ethiopia, whereas most of the 'risk' factors listed are very general and probably quite evenly distributed; many are likely to be just as common in non-African countries.

The most at risk population in Ethiopia, as in many other high prevalence countries, is female, urban dwelling, wealthier and better educated. That does not suggest a mainly heterosexually driven epidemic and shows that many of the 'risk factors' identified by PEPFAR are red herrings. Things that are true of Ethiopia may well be true of the other 11 countries. But PEPFAR will continue to concentrate on sexual risk and ignore non-sexual risk because that is what they appear to have set out to find.

It's odd that PEPFAR should have called Ethiopia's epidemic 'mixed', only to then claim that 87% of the virus is heterosexually transmitted and another 10% is, presumably, indirectly heterosexually transmitted. But they go on to say that neither men who have sex with men nor intravenous drug use contributes much to the epidemic. While it's hard enough to explain very high levels of heterosexual transmission anywhere, the idea that the virus is almost never transmitted through unsafe healthcare or cosmetic practices in a country with deplorable living conditions and 1.2 million HIV positive people is simply untenable.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]

How to Reduce Healthcare Transmitted HIV in African Countries?

noreply@blogger.com (Simon) — Thu, 02 Feb 2012 18:52:00 +0000

"One consequence of the global HIV/AIDS pandemic has been the emergence of a broad awareness of the potential role of syringes in the transmission of infectious diseases", write Nicola Bulled and Merrill Singer in Aids and Behavior. Indeed, several countries experienced sudden drops in HIV incidence, the annual rate of new infections, relatively soon after the virus arrived. These drops occurred long before HIV prevention interventions became widespread, and they are likely to have resulted from the very phenomenon Bulled and Singer note. But more still needs to be done as there is a lot of evidence that bloodborne diseases may still be transmitted through unsafe healthcare.

Of course, HIV industry cant about changes in sexual behavior is legendary. But those changes, if they ever occurred, must have done so much later, particularly if they had any causal connection with the interventions claimed to have turned around some epidemics and stopped others in their tracks. While some sexual behavior change may have occurred, perhaps even as a result of these interventions, the most significant changes probably took place in hospitals and other health facilities, and would have had little to do with sex.

Therefore, the massive increase in 'unsafe' sexual behavior that is said to have given rise to the worst HIV epidemics in the world probably never occurred. which means that the equally massive decreases in sexual behavior needn't have occurred either. But while Bulled and Merrill are right in their statement, the HIV pandemic is still blamed on sexual behavior, and in countries where prevalence is highest, it's blamed on heterosexual behavior. In contrast, where HIV prevalence is not so high, it is known to be more closely related to anal sex and intravenous drug use.

Interestingly for those who believe that HIV is just one disease out of many, and nowhere near the biggest health threat that people in high prevalence countries face, is that use of unsterile injecting equipment is also linked with transmission of hepatitis B and C, Leishmaniasis, malaria and other diseases. In other words, countries where unsafe healthcare is the norm have many reasons to identify dangerous practices and improve infection control, rather than passively accepting UNAIDS' assurance that a very small percentage, perhaps one or two percent of HIV transmission, is a result of unsafe healthcare.

Far from a build-up of unsafe sexual behavior, the authors don't even mention sex, which is unusual in the literature. Instead, they describe a climate of increasing use of injecting equipment throughout the 20th century, in and out of health facilities, by professionals and non-professionals. Through unsafe injecting practices, many diseases can spread to many countries, even many continents.

The authors even mention a myth that has been propagated by numerous parties, including the US Centers for Disease Control (CDC, though they have partially retracted the myth); that HIV dies in seconds outside the human body: it doesn't. HIV and hepetitis B and C can, "given ideal conditions, survive outside the human body for several weeks". They say "HIV has been found to survive in syringes at ambient temperatures for up to 6-weeks". But unsafe healthcare practices are unlikely to require anything like six weeks: instruments could be reused straight away, and many times each.

None of the above denies that HIV can be sexually transmitted but it does put a question mark over UNAIDS' claims about epidemics being almost entirely sexually transmitted in African countries, where some of the most appalling health facility conditions can be found. And UNAIDS don't even believe their own propaganda anyway, because they give the following warning to UN employees:

"The most efficient means of HIV transmission is the introduction of HIV-infected blood into the bloodstream, particularly through transfusion of infected blood. Most blood-to-blood transmission now occurs as a result of the use of contaminated injection equipment during injecting drug use. Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood—to avoid not only HIV but also hepatitis and other bloodborne infections."

If HIV and other bloodborne pathogens are a danger to UN employees in health facilities, this is also a danger to Africans. They need to be warned, just as they are about sexual risks. Otherwise they will be unable to identify risky practices and unable to take steps to avoid them. The authors conclude that "From a public health standpoint, identifying syringe use patterns and their role in specific syndemic events, however, is critical because syringe use presents a discrete point of potential intervention as well as a pathway for the spread of diseases outside of their historic range."

A number of harm reduction measures are recommended, along with improved supplies, education, support to clinical facilities and other steps, which the authors point out are already known. But being known to UNAIDS, WHO and others who wield a lot of power in global public health has not readily translated into action. After three decades of getting to understand HIV better, the extent of non-sexual HIV transmission, particularly in health facilities, is in serious need of investigation. There is a lot that can be done; if various international players feel unable or unwilling to do anything, perhaps African countries need to go it alone.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]

Lies About Sex-Trafficking: a Pre-Olympic Sport

noreply@blogger.com (Simon) — Wed, 01 Feb 2012 16:17:00 +0000

The usual rubbish that comes out in the press before a big international sporting event is back, according to the New Internatonalist: journalists throughout the 'free' press are already salivating about the '40,000 (or some such large number) forced prostitutes' who will be compelled to work during the London Olympics. The same kind of unresearched bumf came out before the World Cup in South Africa and various other sporting events, going back years. It's not even specualtion; there is nothing to support the articles but guesswork and other, equally underresearched articles from other, equally idiotic journalists.

The worrying aspect of the articles before the South Africa World Cup is that the country has some of the worst figures for HIV prevalence in the world. Therefore, half a million or a million visitors (depending on which source you believe) faced a very real risk of being infected with HIV, hepatitis or other blood-borne diseases if they happened to go for a tattoo, dental treatment, medical treatment or any number of other procedures. UNAIDS, despite being aware that such risks exist, choose not to inform Africans, preferring just to warn their own employees. When it comes to Africans, their response is that 80-90% of transmission is from heterosexual contact. But in the run-up to the World Cup, they didn't even warn visitors to the country.

As the New Internationalist points out, the figure is purely imaginary, probably inflated by those who feel all sex work is also sex trafficking. One of the problems with this is that there is little way of telling where the real trafficking is taking place, and therefore where to concentrate efforts to reduce it. But why traffic thousands of people for a very short event, anyway? 40,000 sex workers would barely get enough business from the Olympics attendees who happen to be male, sexually active and remotely interested in having sex with someone who has been forced into the business against their will (as opposed to those who make a choice to be sex workers, for whatever reason).

There are people being trafficked, but if police concentrate all their efforts on commercial sex work, they will have difficulty identifying those who are doing it against their will. And if they think trafficked sex workers will suddenly be easy to find during the olympics, this is not going to be their 'lucky break'. But I'm sure the police know that, even if journalists don't (I'd like to say tabloid journalists but I don't think it is confined to them). Apparently there is increased police activity, with the predictable excesses that go with such measures, but let's hope they quickly realize that they have better things to do.

Luckily, unlike in South Africa, there is little risk of being infected with HIV or anything else through medical or cosmetic exposure. At least, people won't face any higher a risk than patients currently do in UK health facilities. But sudden spikes in media and political interest in such issues doesn't help anyone, the women who are mistreated by the police, women and girls who happen to be trafficked, or anyone. The various illegal practices that surround sex work, which probably arise from the fact that it hasn't yet been decriminalized, are likely to continue, unaffected by the waxing and waning of these mostly trumped-up moral crusades.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]

Confusion About Circumcision Common Where Program is Most Active

noreply@blogger.com (Simon) — Mon, 30 Jan 2012 18:05:00 +0000

Given the amount of money that has been thrown at male circumcision programs purporting to reduce HIV transmission from females to males, a small study reveals that more women than men have incorrect and dangerous views about the operation. However, it is unlikely to dampen the enthusiasm of the HIV industry, which likes to boast that several hundred thousand men have already been circumcised, out of a target of over 20 million.

But the survey also makes the rather dubious claim that female partners of recently circumcised men found sex more enjoyable. I'm sure I have heard that claim before and I wonder if participants knew that circumcised men are more likely to transmit HIV to women. Many people seem to forget that they will still need to use condoms after circumcision, although promoters of the operation are often so intent on pushing the program they pay a lot less attention to condom use and 'safer' sex practices than they used to.

The survey finds that half of the men and three quarters of the women see HIV as less of a threat and that condoms are less necessary after circumcision. A fifth of women said they would be more likely to have more than one sex partner and nearly a third said they would be more likely to have sex without a condom. The authors of the study say there is a need to involved female partners, but that is hardly the only need. Many of the people being circumcised, according to the (not particularly impartial) reports the media like to brandish, are young, single and not yet sexually active. What the study demonstrates is that some people are seriously misinformed by the HIV industry hype around circumcision. If the proponents had done a bit of research earlier, or listened to some of the critics, they would long ago have seen the need for this kind of survey.

According to someone involved in the massive circumcision program in Nyanza province in Western Kenya, many women already do accompany their partners when they go for pre-circumcision counselling. But then the counselling is clearly not very successful. People seem to think circumcision will 'protect' them, which is what they are told. But why should all those who don't bother using condoms now, or the ones who don't always use them, suddenly start using them just because they are circumcised? Why would they even go for the operation if they will still have to use condoms? Wouldn't it be better just to use condoms? Condoms give the highest level of protection known. And while those who currently use condoms may opt for the operation, they shouldn't be at high risk of being infected with HIV.

If people in Nyanza, who are closest and most exposed to the mass male circumcision program are so misinformed about circumcision, what about the 85% of Kenyan men who are already circumcised? Will they think there is any need for them to use condoms? How about their partners, will they know that circumcision only gives partial 'protection' (at best) and that the optimistic figures bandied about are from carefully controlled trials? The conditions found in such trials will not be found in the real world (which seems to be OK for some researchers and for the HIV industry). Those going for the operation really don't know what the outcome will be for them or for their partners and their partners seem to know even less.

Mass male circumcision programs are something of a black box intervention because it is not yet known if they work, and if they do, how they might work. A lot of less well publicized research suggests that the programs will not work, and some show that they could increase HIV transmission. The figures purporting to show that the operation is cost-effective are based on assumed data, as are the projections of how many infections would be averted if all uncircumcised men received the operation.

Incidentally, the modellers who give us such confident projections about the benefits of circumcision have also come up with the claim that, even if a lot of recently circumcised men face an elevated risk of HIV transmission through resuming sexual intercourse too soon after the operation (from female to male if the man is negative, but also from male to female if the man is positive), the net effect of mass male circumcision programs is beneficial. But the net benefits are highly questionable and to accept them, you would need to buy into the whole HIV industry orthodoxy about HIV almost always being sexually transmitted in African countries. Either way, even the potential gains claimed in this paper may not be realized.

[For more about circumcision related risks for males and females, see the Don't Get Stuck With HIV site and blog.]

What Has Gates Learned About Development Since Last Year?

noreply@blogger.com (Simon) — Sun, 29 Jan 2012 17:16:00 +0000

Bill Gates' 'Annual Letter' always makes depressing reading. That someone so single minded about making money and controlling as much as possible [good article in the English Guardian on this issue] should understand so little about development is not as surprising as the fact that, for all his money, he doesn't appear to be able to find advisors who have the balls to stand up to him and get him to at least fake an understanding.

Yet again, to Gates and his cronies, 'innovation' in agriculture in developing countries means wresting the little control left to small farmers out of their hands and putting it in the hands of multinationals, who can squeeze whatever blood is left in the farmers that hasn't already been squeezed out by other means. Technology, as Gates knows, is the preserve of the rich; the rich benefit from it, the poor pay for it. Genetically modified organisms (GMO) and various other technologies that impress Gates so much, and I don't believe he is unaware of this, are not designed to benefit small farmers in developing countries, nor will they ever do so.

In health, also, Gates obsesses about technologies, such as vaccines, single, headline-grabbing diseases such as polio and HIV and issues such as family planning. Yet, over and over again, research shows that it is not just technologies that allow substantial reductions in transmission of common preventable diseases, it is also things like sanitation, water and living conditions. There is no mention in his speech of sanitation and the only mention of water is in relation to GMOs. Polio, which Gates hopes to get credit for 'eradicating', is an example of a disease that will not go away just because everyone is immunized; people need access to clean water and good sanitation. That will help eradicate a whole host of diseases, not just the fashionable ones.

Gates, like a large chunk of the development industry as a whole, thinks that reducing birth rates in developing countries will magically mean that everyone has enough money and enough food. But people need a decent standard of living, gainful employment and food sovereignty. His policies of flying in technologies, whether in health or agriculture, actually increase dependency, poverty and insecurity. If lower birth rates are to occur at all, they will occur as a result of better health, a better economy, better education and the like, not the other way around. And talking of education, Gates is silent on the matter, except for education in the US.

As for HIV, the connection between this disease and enormous profits for Big Pharma is pretty obvious, even to Gates. His foundation has been instrumental in setting up a parallel health infrastructure for this, instead of trying to comprehend how existing conditions in health facilities in high prevalence countries, which are appalling, may have a lot of influence on how the virus spreads. Much of the foundation's money has gone into facilitating the sale of drugs and other technologies and much of the money has never left the US, except to go to US institutions, purpose built in high prevalence countries. Sometimes, the foundation sticks some of the few well qualified health professionals to be found in African countries into a Gates funded institution, just to make the whole thing more African. (For a good example, check out AGRA, the Alliance for a Green Revolution in Africa).

Against the above technocentricity, it's difficult to see why the man should share the HIV industry's obsession with male circumcision. But Gates does mention things like PrePex and the Shang Ring, which will make fat profits for a couple of medical device companies. He seems to think that male circumcision reduces HIV transmission by 'up to 70%', but I think even the most rabid circumcision enthusiasts wouldn't claim that; most would even concede that the up to 60% figure claimed by the HIV industry is from carefully controlled trial conditions with carefully massaged results (though they might not use the word 'massage').

In addition to advocating male circumcision in countries where conditions in health facilities are dreadful and where there are many far higher priorities, Gates goes on to advocate technologies such as injectible hormonal contraceptives, which have also been associated with increased HIV transmission (male circumcision has been associated with higher HIV transmission in as many countries as it has with lower). Unsurprisingly, genuine improvements in health facilities are not part of the Gates Final Solution. And just to demonstrate his fragile grasp on public health, on the subject of antiretroviral drugs to reduce HIV transmission, he says "In studies where the patients used the tool as they were supposed to, the results were quite good." If people don't 'use the tool as they are supposed to', maybe the problem is with the tool.

And the letter goes on and on, with Gates demonstrating his global imperialist ambitions in every sentence, as well as his ignorance of the lives of the people who will suffer as a result. It seems like every year that passes other institutions with imperialist ambitions, such as the UN, World Bank and WTO, also align themselves with this man. Don't expect too many changes over the next year.

What Would Be a Legitimate Role for Western Development Workers in Developing Countries?

noreply@blogger.com (Simon) — Sat, 28 Jan 2012 15:08:00 +0000

There's an interview with Yash Tandon on Pambazuka.org that is well worth reading for people working in development or thinking of doing so. I find it relatively rare to hear what Africans really think of development. My aim in coming to East Africa to work in development was to find out from people working in development here what form development should take. Given that both recipients (as opposed to beneficiaries) of development programs and those working on the programs often agree that things have been going wrong for a long time, how should things be put right?

Tandon criticizes the Paris Declaration on aid effectiveness on the grounds that it was "conceptualized by the donors, and not by the people that were supposed to be assisted". Which is little different from a lot of development decisions, before and after the declaration. Tandon goes on to say that "the so-called development aid never did promote development" and that " The result is that the aid industry has no longer any legitimacy."

It's ironic, considering how often people working in development use the term 'dependency' when referring to recipients of aid, how Tandon turns things around and points out that there are "at least a million people in the Western countries that live off the aid industry". Tandon feels that aid, or whatever term it goes under, was always intended to serve the interests of donor countries. I agree, and Tanzania, with its massive potential for gold, uranium, natural gas, arable land and other resources, is a case in point. The resources remain underdeveloped and underexploited until some wealthy foreign country comes to do the exploiting.

Tandon singles out Oxfam for criticizm as an organization that started out with good intentions but is now part of the very machinery that ensures the smooth operation of aid policies that are intended to benefit Western countries. And he raises a very interesting question: why do we call a lot of 'aid' programming by that name when it is actually just business? The Chinese and the Indians call it business, so why do many Western countries wish to dress it up as philanthropy? It must be a slap in the face to big Western donors to be told that the Chinese do it better when they seem hell-bent on persuading people here that the Chinese are only out for what they can get!

Another couple of sacred cows Tandon slaughters are the imposition of certain 'values', perhaps by church based organizations, which are dressed up as 'solidarity' or some other touchy-feely concept; also the assumption that Western aid agencies have the right to "encourage women who raise their voices against practices that violate their human rights" (for example). Tandon says the latter is not the business of outsiders, that "the initiatives of rural women in Africa against oppression are very strong and very strategic. They know what will work and what will not". I hope his last statement is right; I have not been exposed to initiatives against oppression that are strong and strategic, though I would very much like to be.

These are all perplexing issues for people who wish to work in development without becoming part of the problem, serving as mere instruments of the self-interested Western agenda. Much though I would love to follow Tandon's advice, I have not come across many people who say 'this is what we want and this is how we intend to achieve it'. Rather they tend to say 'how do we get some of this money/assistance/resources'? Perhaps they are now also mere instruments and are currently unable to serve the intersts of those they hope to serve. But how do they change course and set the agenda? If there is an indigenous aid agenda in East Africa, where is it articulated?

I wholeheartedly agree with Tandon's conclusion that "All development is self-development", but I want to work with self-development, with self-developers. I think that the development industry can do a lot more good in developing countries by advocating against certain things, such as land-grabbing, resource theft, imposition of genetically modified organisms and other inappropriate and failed technologies, Western use of cheap labour, exploitation of lax human rights legislation, commodity dumping, unfair trade agreements, etc, something I have called 'Development by Omission' for want of a better phrase. But I wonder if Tandon thinks there is a legitimate role for people who work in development to continue with, as long as they are committed to an agenda set by their adopted country, and if so, what is this role?

Huge Birth Control Programs Don't Work: Time to Give Education a Chance

noreply@blogger.com (Simon) — Thu, 26 Jan 2012 18:07:00 +0000

I recently moved from a job as grant proposal writer for an NGO working in several different development areas to a similar job in a secondary boarding school for girls, which is being built in a country where many girls don't even finish primary school. So I was comforted to find an article entitled 'Women's Education Slows Population Growth'. That women's education can have such profound and positive consequences is not the issue, that has been recognized for a long time, at least by those working in education. But the priority is so often given to population growth, rather than to education or any other development area.

A shocking proportion of 'development' money and a disturbing number of development related insitutions concentrate almost exclusively on population control, in some form or other. They bang on about an unmet need for contraception as if many women will have depleted health or lives as a result of lacking birth control methods, when they are likely to be in far greater need of better nutrition, healthcare, security, governance, equality, infrastructure and, indeed, education. Shovelling contraceptives into rural communities may be a lot easier than providing people with what they need, but without the education and other development areas being addressed, the only gain will accure to the pharmaceutical companies who produce contraceptives.

Similar remarks apply to a lot of other 'health' programs, which target whatever health issue is currently fashionable and well funded; many of them are also necessary, but they would work a lot better if people had the level of education to capitalize on them. Otherwise, they can just go through the motions of attending numerous courses, often for the per diem they may be paid or the free lunch or other minor benefits on offer. I have met people who have been to various 'training courses' only to attend the same course several more times, sometimes provided by the same NGO as before. Training courses are a great way to spend money and it's easy enough to gather data that allows the donor to pronounce the intervention successful. Some health drives pick out some particular disease, perhaps a water borne disease, without addressing water and sanitation in the area. The current drive to 'eliminate' polio is a cases in point; those who attend immunization drives go home to drink contaminated water and contract something else.

Education itself, as we found in my own country, Ireland, is not enough when there are no jobs to go to. And here in Tanzania, women are not considered to be able to do many jobs that they would in fact be well able to do, if they had the education. Sadly, they are considered to be able to do many jobs that are not particularly appropriate for them when they are too young, too old, pregnant, childraising or breastfeeding, but that's another matter. I always feel a bit dishonest when I tell people about how important education is when there is little guarantee many of them will ever get to use it, especially girls and women.

As if there are not enough obstacles, also, school-going girls who become pregnant are excluded from school. In the rare instances where they are allowed to return to school, most do not. This is to 'set an example', we are told. And it does. It shows that girls who get pregnant will be treated very harshly, whereas the boys or men who make them pregnant, generally, will not. The fact that underage girls being made pregnant by older men is a serious crime doesn't get the girls off the hook. Men don't appear to be prosecuted, boys are generally not excluded from school and the strong prejudice against females appears to be practiced by the very institutions that might be in a position to change things.

According to the article, the average birth rate is less than half in regions where education is valued; as I'm working in one of those regions, I'm hoping that birth rates are lower because education is valued. However, even expensive schools with nice, well-funded buildings and facilities, don't always have especially high educational standards. As a fundraiser, sometimes I can see funds for all sorts of things, but not so many that clearly improve education. There is not so much available for good teachers or other provisions that would make a difference. And many fundraisers are tasked with raising money for the buildings, which is important, but often distracts from the ultimate purpose of these buildings.

So, as the article suggests, it's not the correlation between higher standards of education and lower birth rates that is important; it is the priority that is given to education. Proponents of the population control theory of development, so beloved throughout the last fifty years (and still loved by the Rockefeller Foundation, the Gutmacher Institute, the Gates Foundation, Population Services International, Family health Internationa and many more), never appeared to realize what needed to come first, that with development of education, health, infrastructure and the rest, lower birth rates would follow. Similarly, poverty is pervasive in Tanzania, but lower birth rates does not have much direct effect on poverty; rather, lower poverty rates result in improved health, education and the like.

For education to be of benefit, many other things need to be in place as well. But one thing is for sure; reducing birth rates and hoping that other development areas will benefit accordingly has not worked. The funding these charlatans have received urgently needs to be directed towards people's true needs, which are still education, health, a decent standard of living, security, food security and the rest, just as these are the true needs of all people.

Deceived and Misled, HIV Positive People Can Only Speculate About Their Infection

noreply@blogger.com (Simon) — Wed, 25 Jan 2012 19:11:00 +0000

I was intigued by the title of a Kenyan newspaper article: "When a Woman Feels She Is Not 'Rightfully Infected'". I thought that maybe someone was asking how they could have been infected with a virus that is not easy to transmit sexually even though they have never had unsafe sex, very little sex or perhaps no sex at all. Demographic and Health Surveys usually find that a considerable number of people are infected with HIV even though they have no obvious sexual risks. Non-sexual risks are rarely considered and it is usually assumed that people have lied about their sexual behavior.

Anyhow, the article doesn't go that far. A HIV positive woman reflects on the fact that she didn't have enough sex during her marriage to warrent HIV infection. Her husband was working in South Africa and he only came home every six months, which is the only time they had sex. After 22 years of marriage, the woman was diagnosed HIV positive and found that her husband had another wife. Was her husband infected? We are not told. We also don't know if he was infected sexually, whether he infected his wife (the one writing the article) or whether she was even infected sexually.

Leaving aside the fact that the man had another 'wife', in order to establish how someone is infected it is necessary to work out what risks each HIV positive person faces. Even if the man was infected sexually, that does not mean he infected his first wife. She deserves to know how she became infected because if it turns out that her husband is not, and this is commonly the case, it will be implied that she was infected by having sex with someone who was not her husband. This is the HIV orthodoxy: 80-90% of HIV is heterosexually transmitted in medium and high prevalence African countries, though nowhere else. The consequences can be disasterous, with women thrown out of their homes, beaten, dispossessed, even killed.

Far more women than men are infected with HIV in high prevalence countries. Far more men than women engage in 'unsafe' sex. In discordant couples, those where only one partner is infected, it is as often the female partner that is infected as the male; it's approximately 50/50. when genetic typing has been carried out, many couples where both partners are infected are infected with a different subtype of the virus. In other words, one probably didn't infect the other. And even where both have the same subtype, they might not have both been infected sexually. Perhaps neither were infected sexually.

(On the subject of the ratio of male to female prevalence, it's also worth noting that male high HIV prevalence groups are not part of the general population. For example, many men who have sex with men don't have sex with women. Most intravenous drug users are men. Even prison populations, among which prevalence is said to be remarkably high, probably face serious non-sexual risks, such as tattooing, oathing, traditional medicine, intravenous drug use, etc. The actual percentage of HIV positive males who are infected heterosexually is probably a lot lower than the percentage of infected males.)

It may be a long shot, but it's worth checking who infected whom because if it's not the 'obvious' person, it needs to be established how the virus is being transmitted. If someone doesn't often have sex, only has sex with someone who is HIV negative, or has never had sex at all, they should not be infected. There are likely to be non-sexual risks that need to be investigated, particularly healthcare related risks. It's not acceptable to assume that people who are infected with HIV and are African are necessarily liars. But this is generally what happens.

The two women in the article discuss the fact that some people who have little sexual exposure can be infected while those with a lot can remain uninfected. But they seem unaware that some people face substantial non-sexual exposures. They are right that someone could be infected though having sex with a HIV positive person just once; right in theory. But it's highly unlikely. And highly unlikely occurrences like that give rise to few infections. Yet millions of people in some African countries are infected. Something that is highly likely to transmit HIV occurs frequently enough in some countries to give rise to hyperendemic HIV.

So what is it? Unsafe healthcare? Unsafe cosmetic or other skin-piercing procedures? To reduce HIV transmission, we need to know how it is being transmitted. By assuming that it is always sexually transmitted we end up implementing, at best, prevention strategies that may have no influence on non-sexual transmission, whatever influence they have on sexual transmission. At worst, we are just standing by while people become infected and go on to infect others.

To Reduce HIV Transmission From Mothers to Children, Reduce Transmission to Women

noreply@blogger.com (Simon) — Tue, 24 Jan 2012 19:17:00 +0000

In the many articles about eliminating (or virtually eliminating) mother to child transmission of HIV (MTCT), the one strategy I haven't heard mentioned seems like it might be the simplest and most effective of all: eliminate, or at least reduce, HIV in mothers. It has been shown that even very high uptake of prevention of MTCT services will still not allow a country such as Zimbabwe to achieve virtual elimination, which would mean reducing the risk to less than 5%. Even an increase in uptake of services from 36% to 56% only resulted in a drop in MTCT from 20.3% to 18%.

The article states that only an estimated 53% of pregnant women globally got any kind of PMTCT treatment in 2009, which resulted in around 400,000 infants being infected, over 90% of which were in sub-Saharan Africa. But the problem with a lot of HIV programs, PMTCT programs being no exception, is that they are instances of 'vertical' healthcare. HIV related healthcare is, effectively, a parallel health service catering for one disease, while other health services, for better or for worse, cater for anything else the country's health system has the capacity to deal with. But this doesn't mean that HIV services are necessarily good, despite all their funding.

As a result, reproductive health services may or may not include HIV services and HIV facilities may or may not include other reproductive health services. While some HIV facilities may be relatively well funded, at least for their intended purposes, other health facilities are unlikely to be very well funded. In a country like Zimbabwe many people have some access to care but the quality of care is not high, unless you can afford private services. So PMTCT services often don't coordinate well with other services that pregnant woman receive; some receive services early in their pregnancy and drop out, others get later services, but still drop out.

The option of improving all health services and making HIV just one disease among many that reproductive health and general health facilities provide has never been popular in the HIV industry, not wishing to share the funding it receives, which often dwarfs what other serious health conditions receive. So quite a number of women are being infected during pregnancy, even late in pregnancy or just after giving birth. And it appears to be assumed that they were infected sexually, probably while already pregnant, though they may have been in the 'window' period when tested earlier, which could explain why they appeared to be HIV negative.

As a Ugandan woman working with safety in health facilities said to me: 'I refuse to believe that young women (the mean age in the Zimbabwean research was 24), finding themselves pregnant, whether for the first or fifth time, have unsafe sex with strange men on a regular basis; or that women who are in the late stages of pregnancy, or even women who have just given birth, have unsafe sex with strangers; or even that pregnant women have lots of sex with their husbands and resume sexual intercourse shortly after giving birth'.

So what is giving rise to this 1% incidence of HIV, the rate of new infections, during and just after pregnancy? Is it all heterosexual intercourse? If so, all the partners of women who seroconvert must also be HIV positive. Yet HIV rates among men are usually lower than among men; it is highly likely that many of the men are not HIV positive. When African women are found to be infected with HIV, even when their partner is negative, it is assumed that they were infected sexually. But is any effort made to find out if they had other HIV risks, such as unsafe healthcare? Some receive a lot of healthcare, and in some countries women who receive reproductive care are far more likely to be HIV positive.

It may not be a popular view, but the rate of new infections among women taking part in this research is very high, higher than it is in Kenya, Uganda or Tanzania; 1% incidence could result in 8% prevalence or more after only 10 years. In Kenya, Uganda and Tanzania, prevalence has remained static at about 6% for much of the last decade. Why are transmission rates so high in this population in Zimbabwe? Those infected clearly face non-sexual risks, but researchers don't seem to want to ask what those risks are, or to investigate them.

It is inconsistant, indeed futile, to aim to reduce HIV transmission from mothers to their children when it is not even known how the mothers are being infected because reducing infection in mothers is far preferable to waiting until they become pregnant and then offering them PMTCT, and may even be more easily achievable.

[There have been many cases of unexplained and/or unexpected HIV transmission among women, men and children in Zimbabwe and further instances in most other sub-Saharan African countries.]

Keep Using Depo Provera For the Next Five Years; It May Not Be Harmful

noreply@blogger.com (Simon) — Mon, 23 Jan 2012 18:55:00 +0000

The issue of whether use of hormonal contraceptives such as Depo Provera may increase risk of HIV transmission in both directions (from male to female and from female to male) has cropped up on this blog a couple of times and several more times on the Don't Get Stuck With HIV blog. Three months ago, when a paper was published suggesting a possible danger of increased HIV transmission, the WHO, UNAIDS and others recommended doing nothing until they held a 'high level consultation' in January. Apparently that consultation is still on the cards, if this podcast is anything to go by (Podcast 4: Hormonal Contraception and HIV).

The podcast goes through the motions of rubbishing the publication that suggested Depo Provera and similar contraceptives may be dangerous, as various factions of the HIV industry did several months ago. However, their pronouncements on the subject seem somewhat disingenuous; the uncertainty about the safety of Depo Provera, both the pills and the injectible form, runs both ways; things may not be as bad as the research suggests, but it may be a whole lot worse. For those previously advised to keep taking the injections or the pills, they might need to make a decision now. Because trials, we are told, could take four to five years.

It remains to be seen whether people using the product will happily keep using it for four to five years in the hope that the research was wrong and they are in no danger, and that all the evidence produced in the past suggesting that hormonal contraceptives are not safe will turn out to be mistaken, or whether they will stop using the product and wait till they get the all clear, even if that happens to be four to five years from now. I would certainly choose the latter!

Yet again, UNAIDS are advising people who are using Depo Provera, oral or injectible, to also use condoms. Somehow, I don't think people are as moronic as these bureaucrats imagine. Condoms will protect people against HIV and other sexually transmitted infections and they will also prevent unplanned pregnancies. Even if there were no questions about the safety of Depo Provera, many would question the need to use two contraceptive methods. But where there are such important questions it would seem unnecessarily risky as well.

There is a good review of the current evidence about Depo Provera and other issues on the Don't Get Stuck With HIV website, for those who wish to practice safe sex and avoid unplanned pregnancies but don't wish to wait four to five years to find out if their contraceptive method is really safe.

Following Pepin, We Have a Duty to Rethink the HIV Orthodoxy

noreply@blogger.com (Simon) — Sun, 22 Jan 2012 16:56:00 +0000

On page 9 of Pepin's book 'The Origins of AIDS', he writes: "The earliest evidence of HIV in East Africa comes from Nairobi in 1980-1 where 1% of patients with STDs and 5% of sex workers were HIV-1 infected. Just three years later, 82% of Nairobi sex workers were HIV-1 infected." Yet Pepin also spends a lot of effort demonstrating that sexual transmission is too inefficient to start an epidemic. If sexual transmission is inefficient, the percentage of HIV positive sex workers did not go from 5% to 82% in three years as a result of sexual transmission alone. You can't have it both ways and that kind of transmission rate suggests an incredible level of efficiency.

Indeed, Pepin's above two sentences, by their very juxtaposition, could suggest that this is an instance of a HIV epidemic being 'kick-started' through unsafe healthcare. An unrecognized virus has infected a small percentage of people, most of whom are being targeted for STD screening, vaccination and treatment. Nobody at the time had any idea that the process of rounding up sex workers and people with STDs (long-distance truckers, soldiers, etc) to receive healthcare services could at the same time be infecting them with HIV. It would not be inconsistent for Pepin to argue that HIV prevalence doubling every few months could not happen through sexual transmission alone; but he doesn't argue this.

Peter Piot, who spent many years steering UNAIDS away from considering any kind of HIV transmission aside from heterosexual sex in Africa, has piously stated that he agrees with Pepin and, rather outrageously, that he has always been interested in nosocomial infections. But he was the author of the paper published in the 1980s that came up with the above figures about sex workers in Nairobi. While heterosexual HIV transmission was rare in most countries, and that was known when Piot was writing, he seemed convinced that it was the norm in Africa. What should have looked like a massive, though unavoidable, nosocomial outbreak of HIV to someone interested in such outbreaks, became 'evidence' that Africans are not like non-Africans.

Now that Pepin has published his findings and people like Piot have declared themselves to be convinced that non-sexually transmitted HIV must have played a substantial role in creating the most serious epidemics in the world, the least he and the entirely misled HIV industry can do is take another look at how the impossible has happened. Nothing we know about HIV could result in HIV prevalence among sex workers going from 5% to 82% in three years through heterosexual transmission alone. That single paper and that single 'finding' has been cited over and over again. All the more reason for a scientist with integrity to question it in the light of Pepin's findings.

In a way, once it was concluded that HIV was heterosexually transmitted, it was like a self-fulfilling prophecy about African sexual behavior and HIV: those who had been rounded up in the past for their (often assumed) sexual behavior, again became the culprits. All sorts of 'findings' followed, many of which seem questionable now, but continue to be cited; migrants, casual laborers, bar workers, those who spent a lot of time away from home or traveled a lot, partners of all these groups, etc. High HIV prevalence was found in some (but by no means all) of the groups initially thought likely to be infected. But some of those infected would have been infected through earlier unsafe healthcare because they received the very type of healthcare services that Pepin describes, at a time when no one suspected a blood-borne virus had entered the healthcare system.

I follow Dr David Gisselquist, writing on the Don't Get Stuck With HIV blog, in calling for all scientists working with HIV, not just healthcare professionals, to gather up earlier claims (and perhaps more importantly, assumptions) about sexual transmission of HIV and look at them again in the light of Pepin's findings. We no longer need to accept the sort of racist and sexist assumptions about African sexual behavior that have passed as 'knowledge' about HIV. We are now free to rethink the HIV orthodoxy; in fact, we have a duty to do so.

How Many Dictatorial Bureaucrats Can You Fit in a Five Star Luxury Hotel?

noreply@blogger.com (Simon) — Sat, 21 Jan 2012 16:04:00 +0000

It's discomfiting to hear that Uganda's male circumcision program is being described as 'failing' by a journalist. However, what the journalist actually says about the program is that they really haven't a clue how it is going. Of course, the journalist may know something that is not mentioned in the article. But knowing very little about an expensive, highly politicized 'health' campaign, and one that is concerned (ostensibly) with reducing HIV transmission, is certainly a failure of sorts; think of the publicity.

The Ugandans should take a leaf out of the Kenyans' book and just make up the figures. There's nothing a foreign donor likes more than to hear that everything is going well and few things they hate more than to hear that those involved are indiscreet enough to tell the truth, even if it's an admission that they really don't know how many people have been operated on.

The Ugandans could even just adopt their current strategy on reporting numbers of people on HIV drugs; they don't take too much notice of the substantial percentage that is lost to follow-up every year, those who die or those who develop resistance to the 'cheap' drugs, if they even notice the last issue at all. Many of those being counted could have died or could be getting double counted because they are registered for drugs in several places, which is done because Uganda has never been able to get its drug supply capacity quite right.

The article claims that there is a high demand for circumcisions, which is surprising when the same sentence also says it's not known how many men are receiving the operation. Apparently "most of the institutions carrying out circumcision don't share their data with the ministry of Health". So the journalist and those interviewed are, effectively, just guessing. Which is not really a problem, after all, as those publishing 'figures' purporting to show that male circumcision has any appreciable impact on HIV transmission are entirely unable to say why such an operation should work in the way they say it does, nor why it only seems to work as often as it clearly doesn't work. They too are just guessing.

As for various health facilities not sharing data, I guess that's no more horrifying than the admission that data is not always even shared with people taking part in some of these studies. HIV positive people are not always told they are HIV positive, their partners are not always warned, etc. This wouldn't happen in the countries from where the money emanates for this research, but it appears that ethical standards paid for by big donors, such as Gates and whoever he fronts for, don't apply to Africans. Like Tuskegee (which is so often mentioned in these contexts), it may come out in a few decades time, but for now, people who are known by medical professionals to be HIV positive are allowed to leave health facilities and infect their partner or partners, and no parties need be informed.

The commissioner for National Disease Control, Dr Alex Opio, does "not have a single figure on the great work being done": so how does he know how great it is? I'm glad he has spotted that there is a need to "address this immediately", but shouldn't he wait till he knows what is going on before commenting so liberally? Aren't there laws about telling the truth to journalists when there are important international donors involved?

In a sense the commissioner is right: such 'data' is being used for 'evidence-based medicine'; the whole circumcision (for Africans) program is based on such questionable evidence. Despite citing the rather far-fetched figures ("4.2 million adult/adolescent men need to be circumcised in five years to avert 340,000 new HIV infections by 2025"), the commissioner does realize that a lot of foreign money is pulling out. But enthusiasm for circumcision still seems to be as keen as ever. Other figures cited are equally disturbing, such as the 20.3 million Africans that 'need' to be circumcised, which we are assured will 'prevent' several million infections and save 16.5 billion dollars in treatment costs.

In stark contrast to all the rhetoric about democracy, good governance, accountability and the like that we hear from some of the more pompous and sanctimonious representatives of the HIV industry, some of the least accountable and most undemocratic institutions the world has ever known (as for governance, we don't know, they are unaccountable) have developed a framework 'in consultation' with national ministries of health.

Institutions listed include "the World Health Organization, the Joint United National Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the World Bank". While we have little idea how many Ugandan men have been circumcised under the current program, we can gain some idea of how much of the HIV industry funding will be spent, given that particular bunch of overpaid bureaucrats.

[For more about non-sexual HIV transmission, such as through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]

Is it Already Too Late For People to Reconsider this Circumcision Farce in Africa?

noreply@blogger.com (Simon) — Thu, 19 Jan 2012 19:34:00 +0000

According to an article on IRIN's PlusNews there is 'good progress' being made in the male circumcision program in Tanzania, which presumably means that they are going to get away with performing hundreds of thousands, perhaps millions of operations, knowing that the overall positive result will be small at best and there will be a lot of adverse events, perhaps even serious ones. It's clear that people pushing for these programs are not in the least bit worried that they will have to bear the costs of any adverse events. Who knows, perhaps they'll even profit from them.

But it's not unusual for circumcision 'experts' to make light of the subject. It is also claimed that the goal is to circumcise 2.8 million men by 2015 in a country where many people die of cheaply and easily preventable and treatable conditions every day. Many tens of circumcisions will need to be carried out just to prevent a single HIV infection, if the figures we are constantly blasted with are right. Where prevalence is particlularly low, hundreds of circumcisions will need to be carried out to prevent a single infection.

The program is being rolled out in Iringa at the moment, where HIV prevalence is much higher than anywhere else in the country. Yet it's certainly not the only area where circumcision rates are low. There are many areas within high HIV prevalence countries where circumcision and HIV are positively correlated, as well as areas where they are negatively correlated. In other words, we don't know what the connection is between HIV and circumcision and we certainly don't know why so many people are becoming infected in just some areas.

Are we supposed to believe that people in Iringa have amazing amounts of sex, unlike, say, the people in Arusha, Moshi or Kigoma, where HIV prevalence is far lower than the national average? Or perhaps we are supposed to believe that HIV prevalence in cities, particularly Dar es Salaam, are high just because of love levels of circumcision. In some places where birth rates are very high, such as the Northeastern province in Kenya, HIV prevalence is less than one percent. People there are clearly having sex, unless there has been a sustained outbreak of virgin births in the area. But the claim that there has been such an outbreak is no less ludicrous than the claim that HIV prevalence is high in some countries purely because of sexual behavior or, even worse, because some of the men are not circumcised. Circumcision rates are very high in Northeastern province, but they are also high in Western Kenya, where HIV rates are high too.

There is some evidence of mission creep in this program: originally these crazy claims were about adult male circumcision. Now, some articles mention infant circumcision and this one about Tanzania says that the 2.8 million people includes men from 10 years old to 34 years old. The cost of all this is estimated at between 28 and 47 million dollars, which would probably be enough to completely eradicate far more serious conditions, such as obstetric fistula, and still leave some change to train some much needed health professionals. By the way, nurses have been trained to do the operation in Tanzania and elsewhere, as there are not enough doctors.

It's worth bearing in mind that circumcisions are more common in urban areas, where HIV is less common. But that might change. Earlier circumcision programs suggested that some men could have been infected with HIV as a result of unsafe healthcare they received. This was very inconvenient and the embarrassing results were not published for journalists and other commentators to rant about, but I wonder if they would even have bothered. It's too late for the hundreds of thousands of Kenyans claimed to have already had the operation, probably unnecessarily, and the tens of thousands of people in other African countries. But there is still time for some African countries, or African people, to get some impartial advice about this subject, which is now top heavy with industry lies.

Doubts About Male Circumcision and the HIV Industry's View of African Epidemics

noreply@blogger.com (Simon) — Wed, 18 Jan 2012 18:42:00 +0000

Even the title, 'Not a Surgical Vaccine', flatly contradicts the claims of circumcision enthusiasts; the term 'surgical vaccine' is rejected for being entirely unscientific. But it's in good company with many of their other claims. Authors Robert Darby and Robert van Howe look in particular at the issue of infant circumcision in Australia which aims to reduce heterosexual HIV transmission. They find there is no case for this intervention.

The authors question the 'robustness' of the three African trials constantly cited in favor of mass male circumcision and find that possible risks of such an intervention are being ignored. They also raise questions about the ethical and human rights implications of such programs, which are already well underway in a number of African countries. The authors recommend that Australia continues to discourage infant circumcision.

However, many of the reasons for finding the pro-circumcision arguments unconvincing are also relevant to African countries; they are also relevant to adult male circumcision. The authors ask if the incidence of heterosexually transmitted HIV is rising to a dangerous level and whether circumcision is the only effective way of countering this challenge. In high prevalence African countries it would be better to demonstrate how heterosexual HIV transmission is so much more common than elsewhere. As for the question of whether circumcision is the only effective way of countering HIV transmission, it is not particularly effective; but there are effective ways.

For example, condoms are very effective at reducing HIV transmission. But also, male circumcision only reduces transmission among men who also use condoms all the time. In other words, it is pointless unless men are going to use condoms on all occasions where they are not aiming for conception. The condoms won't just prevent conception and HIV, they will also substantially reduce the risk of transmission of all sexually transmitted infections (STI).

The authors list six reasons for disputing the proposal that all infant males be circumcised in Australia but with the exception of number two, they all cast doubt on the circumcision programs in African countries, whether for infants or for adults:

1 [The proposal] ignores doubts about the African evidence on which it relies and passes over numerous critiques of the clinical trials and the manner in which the WHO recommendations arising from them have been implemented.
2 It is irrelevant to the Australian situation and the specifics of Australia's HIV problem.
3 It departs from the principles of evidence-based medicine.
4 It underplays the harm and risks of circumcision.
5 It violates accepted standards of medical ethics and human rights.
6 It is marred by unscientific thinking and hyperbolic language, such as the description of circumcision as a ‘surgical vaccine’.

In addition to a whole host of criticisms of the randomized controlled trials, the authors say "Perhaps the most crucial flaw in these three studies is that the researchers assumed that all the men who became HIV positive during the course of the trials were infected through sexual contact." But that flaw can be found in many trials of HIV prevention interventions, perhaps most. The authors suggest that as much as half of the infections were acquired non-sexually. And the authors also note the lack of a convincing biological explanation as to how circumcision is supposed to protect against HIV and other STIs.

It's interesting that the authors combine scepticism about mass male circumcision campaigns with less than whole-hearted acceptance of the HIV industry view that serious HIV epidemics found in African countries are a result of high levels of sexual activity. They suggest that "It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures." I hope these researchers' findings are applied, as they should be, to countries other than Australia, where HIV rates are extremely high. Their findings have implications for the entire HIV industry view of HIV in African countries, not just the doctrinaire decision to fund mass male circumcision campaigns.

[For more about healthcare associated HIV infections, see the Don't Get Stuck With HIV site and blog.]

Sex Workers Face Sexual and Non-Sexual HIV Risks

noreply@blogger.com (Simon) — Tue, 17 Jan 2012 19:26:00 +0000

A survey into HIV/AIDS among female sex workers (FSW), injecting drug users (IDU) and men who have sex with men (MSM) in Lebanon has found that prevalence was 3.7% among MSM but that no members of the other two groups were HIV positive. Whatever about IDUs, it is not too surprising that no FSWs were infected. In many countries where HIV prevalence has been monitored over a long period of time, prevalence among FSWs has been found to be low, even zero, unless they also face other risks such as injecting drugs.

This is what makes it so surprising that HIV prevalence can be extremely high among sex workers in some African countries. It has been claimed that prevalence reached over 80% among sex workers in Nairobi in the 1980s and over 70% in one region in Tanzania in the 1990s. It is often said that high rates of sexually transmitted infections STI make sex workers more susceptible to HIV. This is undoubtedly true, but rates of some STIs, which are an indication that those infected could have been engaging in unsafe sex, don't seem to correlate with HIV rates.

Programs that aimed to reduce STI rates have often been successful, but they have not usually resulted in any reduction in HIV incidence. Indeed, long before HIV was identified, STI prevalence among the entire male population of Leopoldville in the former Zaire in the late 1950s was extremely low. And it was in the years following this that HIV transmission rates were said to have increased as a result of extraordinary levels of 'unsafe' sexual behavior. What seems more plausible is that FSWs in Kenya and Tanzania were rounded up, perhaps routinely, to receive sexual healthcare that may not have been too sterile.

Sex workers everywhere can engage in high levels of 'unsafe' sex, but only in a few countries have sex workers been found to have such massive rates of HIV infection. And only in a few countries have up to 50% of the female heterosexual population in certain age groups been infected with a virus that can be transmitted sexually, but is far more efficiently transmitted through unsafe healthcare. Why should high levels of 'risky' sexual behavior among Lebanese sex workers result in no HIV infections when relatively low levels in some African countries result in high rates of HIV infection?

Pandemic HIV: Not as Perfect a Storm as we Have Been Led to Believe

noreply@blogger.com (Simon) — Mon, 16 Jan 2012 18:28:00 +0000

In his review of Jacques Pepin's 'The Origins of AIDS', Peter Piot (Science 334 (6063):1642-1643, 2011) claims to have been "fascinated by the sometimes devastating consequences of medical injections" since the mid 1970s, following the Ebola virus outbreak in the Democratic Republic of Congo. That's strange, because I've never been able to detect that fascination in his papers. Perhaps his fascination is dormant, a bit like one of the HIV virus strains Pepin describes, which never get beyond infecting one or a handful of people.

Anyhow, now that Pepin has described the role of healthcare in spreading HIV, especially in the decades before the virus was recognized, maybe Piot will develop all those thoughts which never quite became papers. Perhaps his ideas will 'go viral', mobilize UNAIDS and the entire AIDS industry to relinquish their more evident fascination with the sexual behavior of Africans, and perhaps result in thorough investigations of the many suspected cases of healthcare transmission of HIV that have been ignored for so long.

But like Pepin himself, Piot jumps from high rates of HIV transmission as a result of unsafe healthcare to high rates of HIV transmission as a result of 'unsafe' sexual behavior, as if unsafe healthcare completely died out in the 1980s and ceased to play any significant role over the last twenty years or so. HIV transmission from unsafe healthcare did begin to reduce shortly after it was recognized as playing a part in spreading the virus. And in countries where healthcare practices were modified to avoid HIV transmission, HIV incidence, and eventually prevalence, began to drop.

But the massive increase in unsafe sexual behavior that was said to follow urbanization and various other (often rather vaguely described) changes in the 1970s and 1980s may never have happened, or may never have played as big a role in HIV transmission as the industry claims. Of course, sexual transmission of HIV occurred, and still occurs. But with healthcare producing large enough populations of HIV positive people, relatively normal (for human beings) levels of sexual behavior would have resulted in additional infections, much as sexual behavior continues to contribute to epidemics now, albeit far more modestly than is sometimes claimed.

The idea that healthcare related infections no longer occur, or hardly ever occur, is a matter for investigation. Piot and Pepin may be right, or even somewhat right; but there is a lot of empirical work to be done. The need for empirical enquiry into the possible extent of healthcare transmission has been obvious for many years, many people have called for the work to be done. But all that people like Piot have done is supported UNAIDS and the industry in denying a role for anything except sex.

Glass syringes are no longer used and disposable syringes, presumably, are not reused (very often). But how does the industry feel so confident that there are no practices in healthcare facilities which, if carried out without proper care, risk transmitting HIV and other bloodborne diseases? The 'perfect storm' metaphor that Pepin mentions and Piot echoes, one that is currently so beloved by journalists and other commentators, doesn't appear to be appropriate here. They both refer to a series of events that gave rise to the HIV pandemic, rather than concurrent events.

Pepin's Spectacular 'Origins of Aids'; Looking Forward to Part II

noreply@blogger.com (Simon) — Sun, 15 Jan 2012 16:31:00 +0000

I have been reading Jacques Pepin's recently published book 'The Origins of Aids'. He has produced a huge amount of research and thinking on the issue of where HIV came from and how it spread all over Africa and beyond in a relatively short space of time. He also considers some competing theories and proto-hypotheses and effectively shows why they do not provide an adequate or comprehensive explanation, either because they are not borne out by evidence or because they don't show what they purport to show.

Few would disagree with Pepin's conclusions that unsafe medical practices 'kick started' what became the current HIV pandemic, a process that was required for a virus that was difficult to transmit sexually to eventually infect people who were not sexually active, or not particularly so. Also very clear is one of Pepin's lessons learned: that profound social changes resulting from colonization, urbanization and the like, were highly significant.

But this is where I start to feel less convinced by Pepin's further remarks on what 'profound social changes' is usually taken to mean for HIV: sexual behavior. Pepin speculates about how 'unsafe' sexual behavior could have reached levels that explain later explosions in HIV transmission, but he never shows that enough people actually engaged in the requisite quantities and types of this behavior to account for some of the very high, or even medium prevalence epidemics.

In fact, since detailed figures have been collected, the connection between sexual behavior, unsafe or otherwise, has never been very strong. This is not to say that sexual transmission of HIV has never occurred, just that it has never been shown how it could reach a creshendo and then, as if spontantously, reduce and drop to a very low and steady rate, at least in some countries. But the drop in incidence (and/or the drop in 'unsafe' sexual behavior) does 'appear' to have been spontaneous in some countries, occurring long before any serious HIV reduction programs took place.

Vulnerable groups, such as sex workers, are small. If they face very high risks, their clients face higher risks than they would if they stuck with a single regular partner; but they face lower risks than the sex worker. And partners of sex workers' clients face lower risks still. Prevalence in the general population in some countries, people who did not belong to any high risk group, has often been higher than prevalence in extremely high risk groups in non-African countries; how do extreme levels of transmission among those who face the highest risks also arise in those who don't face the highest risks? I've never been convinced by talk of 'bridging populations', people who have sex with high risk groups and spread the virus among low risk populations.

For example, HIV prevalence among sex workers in India is less than 10%, often a lot less. But HIV prevalence in one whole region in Tanzania and among one large tribe in Kenya is two or three times higher. In some countries, such as South Africa, Swaziland, Lesotho, Botswana, Zambia, Zimbabwe and others, prevalence in the general population is many times higher. In some African countries, ordinary people doing ordinary things are infected with a virus that is difficult to transmit sexually and it is assumed that most of them were infected sexually. Is this not illogical? Even UNAIDS produce figures showing that the majority of HIV transmissions in many African countries result among people who have no obvious sexual or other risks.

Pepin seems to go beyond his own evidence in concluding that although unsafe healthcare played the major part in the spread of HIV at one time, that it no longer plays a particularly significant role. He may be right, but I don't see how this conclusion is borne out by evidence. In fact, just as there is still a serious lack of convincing research into sexual behavior in African countries, there is an even more glaring lack of investigation into instances where HIV has clearly been transmitted in healthcare facilities and in contexts where sexual behavior is unlikely to have played a part.

Over thirty years, it has become quite evident that sexual behavior doesn't miraculously change because of some perceived threat, such as HIV. For several decades before HIV was identified, the bulk of health development spending was thrown at persuading African women, and the donor community, that birth control would solve all their development problems, poor health, poverty, malnutrition, drought, famine, flooding, etc; if only people would just have fewer children. Many still believe it, Bill Gates being no exception in that respect.

What can change very quickly is practices in health facilities, if the right training and other resources are available. The spontaneous event that resulted in a sharp reduction in HIV incidence early on in various African country epidemics (and elsewhere) is unlikely to have been related to sexual behavior; but changes in healthcare practices took place very early on, especially in countries where such changes were affordable. Even in Western countries, some of the largest groups infected were haemophilics and others who regularly needed various forms of skin-piercing healthcare.

I wonder why Pepin didn't answer the often asked question: 'What happened in Uganda'. He had the answer at his fingertips. Uganda reacted to advice that was still given to developing countries in the 1980s, but is considered unmentionable now: HIV can be transmitted most efficiently through contaminated blood. Pepin shows us how amazingly common non-sexual transmission was in the past but he doesn't appear to have looked into how common this mode of transmission might have continued to be for the last twenty years or so, or how common it is now.

[I have also written about Pepin on the Don't Get Stuck With HIV website and blog, where we are trying to collect together cases of nosocomial (hospital acquired) HIV outbreaks, unexpected HIV infections and investigations that have taken place around the world.]

Branding Duesberg is Easy But Refutation Seems to Elude HIV Industry

noreply@blogger.com (Simon) — Mon, 09 Jan 2012 17:13:00 +0000

Nature notes the publication of Peter Duesberg's controversial article in an Italian journal, where it is claimed that there is no proof that HIV causes AIDS. The article was previously published and then withdrawn, but the publishers, Elsevier, still make it available for a fat fee.

Anyhow, Duesberg's claim is no stronger now than it was when he first made it. His arguments are partly based on data which he himself points out is often not available. But, instead of supplying the data on which, presumably, the contrary arguments are based, all we get is a few protests that Duesberg's article was published at all, and the predictable rantings of the HIV industry sponsored comment junkies.

The publicity conscious HIV industry should be well aware of how they are drawing attention to Duesberg's views, while failing to deal with them satisfactorily. But the industry is really not good at producing well-rounded data, which would allow convincing opposition to Duesberg and allow the industry itself to put together a coherent argument for their own position (or positions).

Apparently, one of the reasons for withdrawing the original publication of the article was that it contained opinions that "could potentially be damaging to public health". But that's not a reason for refusing to publish them in a journal that hardly anyone reads. In what way would public health be served by not publishing the article? At the very least, Duesberg has pointed to serious failures on the part of WHO and other institutions to collect and publish data that is vital to public health.

If public health is really the issue, evaluate the paper properly, publish the evaluation and get on with something more important. Otherwise you are just recruiting for Duesberg and the whole issue becomes a mere exercise in protecting various theoretical pitches.

How Low Would An NGO Go For the Sake of Money, Even Spite?

noreply@blogger.com (Simon) — Wed, 04 Jan 2012 19:03:00 +0000

The first time I came to East Africa, in mid-2002, I wondered how I could be part of 'development', part of the efforts to change things for the better (despite knowing that some things that go under the name 'development' make things worse, often by design). The changes may be small, but they would make a big difference to some. Etc.

Like anyone else who had similar wishes, I needed to find out what was going on, what was so bad that it needed changing, how to bring about such change, why this sort of change was not already occurring, or if it was, how to do more of that and less of anything that was inimical to development...

I wanted to meet people involved in development, people from East Africa, people not from East Africa, whatever it took. I went back to Europe to save enough money to return and, at the same time, study for a Master's degree that included development, and perhaps some other areas, so I would have some kind of perspective, maybe even some useful skills.

That may all sound very naive, but in some ways I haven't changed that much. Since I've come back I've been working with individuals, community based organizations (CBO), non-governmental organizations (NGO) and the like, hoping to find that some were doing the right thing so I could learn about where I could fit in. Because, as I spend time trying to find out where I fit in, I have to do something. So I do many things, and I hope that continues.

But what do NGOs and others in the developing world do? Well most people know something about some NGO, what might have once been referred to as 'charity'. They do relief work following emergencies, education of various kinds, healthcare work, poverty reduction work and much else. Nominally, they do all the kinds of things that someone 'with a heart' would wish to do, or wish to know that others do or to support, financially and in other ways.

Well, some people do things because they 'have a heart', but not all do. Some make a living out of their work, some make a very good living, some make a fortune, etc. But one expects NGOs themselves to be run, driven perhaps, by 'a heart', whether it's the heart of a person, several people or some kind of community, perhaps a church.

Many organizations in East Africa doing development work are, to a greater or lesser extent, church-based. Now, we all know from experience that being church-based does not guarantee that the work is always well intentioned. Unless the people driving the organization have good intentions, the work will be of little benefit to people who are in need of, say, education, poverty reduction, healthcare, and the like. As I've said, some 'development' work is harmful, and the ideal of 'making things better', however naive-sounding, was never part of the plan.

Perhaps I'm rambling a bit; that is partly my want, but partly my intention, for the moment. But you do come across organizations who say all the right things, tick all the right boxes and go through all the motions, and all that just to survive as an organization. There is nothing else they can do but survive. They look for calls for proposals, find ones they think they can do or ones they can persuade the donor they can do, and apply. If they get money, they do the job, somehow or other, if not they collapse.

So take an organization I shall call whateverisexcellent.or.tz; they are a church-based organization, they do all of the above and everyone says that they are very good proponents of their church's teachings. They 'help' poor people, sick people, vulnerable and abandoned people, people with disabilities, people who are in some way stigmatized, they care for them and look after them, up to a certain point; they are unlikely to do so for the duration of those people's lives, unless those lives are short (and many are); projects are usually a few years and no more.

But that's something, because they are doing what they say they are doing, donors love them, they give them money and every few years, when a project ends, they can apply for more money and say 'look at these children and old people and orphans and vulnerable children and disabled people and stigmatized people, this is what we have been doing, if you give us more money we will keep doing it and even find some more beneficiaries'.

But when it comes down to it, the organization is just part of a bigger community, which is part of an even bigger congregation, which is part of a whole lot of congregations and overlapping groups. And it happens that whateverisexcellent.or.tz has a neighbour, which whateverisexcellent.or.tz's church was able to help out with some land, so that this neighbour could build another NGO, specializing in some of the above needy groups; let's call the neighbour ladlesoflove.or.tz.

Ladlesoflove.or.tz, as an organization, do very well. So well that the church sees the beautiful buildings and, maybe, they 'covet' them. Whateverisexcellent.or.tz may well tick all the right boxes when it comes to applying for grants and, eventually, reassuring donors that they have spent the money well (and asking for more, of course), but they covet the assets of ladlesoflove.or.tz so much that they ignore the vulnerable, poor, disabled, abandoned, stigmatized beneficiaries of ladlesoflove.or.tz; they threaten to evict their neighbours, to whom they were once so sympathetic.

For me, the question is, if whateverisexcellent.or.tz is so concerned about all needy people, some of whom ladlesoflove.or.tz is benefitting, how could they do something that would compromise every single beneficiary? And just for the sake of some assets (plus a fair amount of spite, jealousy, bloody-mindedness, prejudice or anything else that drives such maneuvers)? Shouldn't their donors say 'hey, why do you take our money but continue to impoverish the poor, stigmatize the stigmatized, abandoned again those who have been abandoned?'

If donors don't do that, they are simply accepting that development is just an exercise in identifying some projects that can tick the right boxes, and getting on with the job. So is that all development is? As a person still trying to figure out what development is, I certainly don't accept that it is, effectively, an administrative and PR effort entirely motivated by political and/or commercial interests, with no intentions worthy of a human being as a human being. If development is just another business, and just as unscrupulous as it needs to be, I think many people working in the field will be looking for another way of fulfilling their original intentions.

I'll return to this theme soon and I hope to be clearer about whateverisexcellent.or.tz; are their intentions honorable, or is all the 'we're a church-based organization and we follow the teachings of the bible' just posturing, just a way of keeping the donor funds flowing. Because I've heard many claims about 'following the teachings of the bible' and (sharp intake of breath), some of them sounded quite hollow. But that's just my view.

Are UNAIDS Really Giving Good Advice to Malawians?

noreply@blogger.com (Simon) — Sat, 31 Dec 2011 13:42:00 +0000

This could be a good time for condom manufacturers to get involved in large scale HIV prevention campaigns in African countries. After all, it must represent a huge market. But the figures for HIV prevalence among condom users are not always very encouraging. In fact, reported condom use often seems to be associated with far prevalence than those who claim not to use them.

The latest Demographic and Health Survey for Malawi is a case in point. Among women who had ever used condoms, HIV prevalence was 20.3%, whereas among those who never used them it was only 13%. Among men who had ever used them, prevalence was 11.8% but among those who never did was only 5.8%. Those are substantial differences.

Similar trends are found among men who have paid for sex in the last 12 months. Among those who ever used condoms, prevalence is 11.5% but among those who never did it was 4.1%. Even those who did not pay for sex in the last 12 months had far higher prevalence than those who did pay for sex and did not use condoms (or did not have sex in the last 12 months), at 9.3%.

Why does condom use seem to be associated with far higher HIV transmission rates in many African countries? We know they work to reduce sexual transmission of HIV and other sexually transmitted diseases, so what could be going on in Malawi? It seems surprising that condom manufacturers are not taking a careful look at these figures.

The report also finds that: "Among respondents who have never been married, the HIV prevalence [...] 2 percent for those who have never had sex. This suggests that some women and men incorrectly reported that they were not sexually active, or that there is some degree of nonsexual HIV transmission occurring (e.g., through blood transfusions or non-sterile injections)."

Granted, some people forget, lie, or misreport, in Malawi and everywhere else. But even those who have reported high levels of 'unsafe' sexual behavior are just as likely to have been infected through some non-sexual mode of transmission as those who have never had sex. After all, sexual transmission is less efficient than many non-sexual modes.

HIV rates by circumcision status also appears to be very mixed. In almost every age group, HIV prevalence is higher among circumcised men and overall prevalence stands at 10.3% for circumcised men and only 7.6% for uncircumcised. Given that a lot of Malawian men are not circumcised, let's hope the circumcision enthusiasts figure out exactly what's going on here before rushing in and carrying out an operation that doesn't decrease transmission and may increase it. There are already claims that about 250,000 Kenyan men have been circumcised to 'reduce' HIV transmission.rends

There are also the trends that you will find in other high prevalence African countries. For example, prevalence is far higher among women, roughly a 60-40 split. When you consider that most of the high risk groups that don't involve sexual transmission, intravenous drug users, men who have sex with men and prison populations, are almost all men, it makes you wonder how women can face such high risks.

Prevalence is twice as high in urban areas and varies a lot between different regions and different tribes. Prevalence also varies considerably among religions, with Anglicans having the highest prevalence, Catholics the lowest and Muslims somewhere in between.

Higher or lower levels of education are not clearly associated with HIV prevalence, with almost the same rates among those with no education and those with higher than secondary level. Employment status is a lot clearer, with rates being far higher among employed people than unemployed people.

As is often the case in high prevalence countries, wealth appears to be highly positively correlated with HIV prevalence. This is especially the case for women, where prevalence among the lowest quintile is 8.9%, rising steadily to 19.7% among the highest quintile. For men, the figures are 5.6% rising to 10.8% in the highest wealth quintile.

I'm all for promoting interventions that work and condom use is one that certainly does work to reduce sexual transmission of HIV. But there are always figures in Demographic and Health Surveys that make one wonder what proportion of HIV really is transmitted sexually and what proportion is transmitted through other routes. Many of the figures for Malawi, though, seem to suggest that a lot of HIV industry advice is really not very effective.

AgriSol in Tanzania: Land-Grabbing or Outright Theft?

noreply@blogger.com (Simon) — Wed, 28 Dec 2011 12:37:00 +0000

Tanzanians and other Africans seem to be worrying a lot about reductions in foreign aid and what conditions will need to be met in order to receive whatever is available. But they don't seem to be paying much attention to the fact that land is being grabbed by foreign multinationals at a rate that involves far higher sums of money than foreign aid.

The Oakland Institute has investigated AgriSol's dirty deals in Tanzania and though they have been found wanting, they appear to be going ahead. Many Tanzanians suffer regular food shortages and poor diet but Agrisol intends to use huge tracts of land and substantial amounts of water to produce biofuels and genetically modified crops for export.

Aside from needing land and water to produce food and other things, Tanzania is not yet prepared for genetically modified organisms. Even if they have some kind of regulation, probably regulation that suits the likes of AgriSol more than it does Tanzanians, the country is unlikely to have the capacity to enforce appropriate regulation any time in the near future, which should suit the GM industry.

AgriSol and others involved in these land-grabs like to claim that the land is marginal and/or underutilized, even uninhabited, none of which are true. Biofuels and genetically modified crops, despite claims to the contrary, need water and fertile soil. So AgriSol want to bribe (or whatever the current nomenclature is) their way into 800,000 acres of fertile land which is inhabited by over 160,000 people.

Of course, AgriSol also claim they will be enriching Tanzania and the local communities who will be effectively dispossessed and displaced. AgriSol will not allow such matters to get between them and hundreds of millions of dollars profit. So they need the assistance of public relations experts, legal experts and, of course, political allies. And with that amount of money to be made, this assistance should be readily available.

The Oakland Institute have published eight myths they have identified about land-grabbing, and in particular about this current AgriSol intrigue. The first is that the land is not being used, which most land-grabbers claim. The land is inhabited by displaced Burundians, some of whom have been there for nearly 40 years, having been originally displaced by war.

AgriSol also claim they are not involved in the displacement of Burundians, which they say started independently of their efforts. This claim does not stand up to scrutiny. Their claims about cooperating fully, consultations, transparency and the like are also untrue. All the big land-grabbers claim that Africans will benefit, AgriSol being no exception, even taking steps to ensure that they can export food crops at times when there is a lack of food security in the country involved.

Indeed, AgriSol will be looking for a tax exemption and they will want to receive input subsidies that are currently destined for Tanzanians. So much for private enterprise eschewing subsidies! AgriSol go through the usual sanctimonious posturing about environmental responsibility, which simply doesn't add up for either biofuels or genetically modified organisms, which are both extremely destructive to the environment.

Very small numbers of people will be employed by AgriSol's scheme and fewer still are likely to be Tanzanians. And the amount of 'rent' they will be paying is a derisory one tenth of a dollar an acre for a 99 year lease. Good agricultural land costs in the region of millions of dollars, so it's not clear how rental revenue will even cover the costs of the paperwork.

The Oakland Institute unearths many disturbing things about AgriSol and the various well connected people involved, who seem to be more scrupulous about maximizing earnings than anything else. Sadly, there will be a few in Tanzania who will be able to pick up a nice fee for selling their friends and families. But Tanzania as a whole and ordinary Tanzanians will lose a lot more than they stand to receive in donor funds, no matter what conditions they agree to.