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Pre-Exposure Prophylaxis: Risks in the Pipeline?


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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIV in ‘Africa’:12 Steps to Unknowing Knowns


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

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

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

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

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

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

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

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

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

Choke on it: Peak Free Lunch at HIV Inc?


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

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

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

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

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

Here are some ways that a lot more could be achieved with a lot less money:

  • Trace the possible source of every new infection; every new infection is potentially the source of more than one further infection, so failure to trace sources represents one of the biggest missed opportunities of the last 30 years of providing HIV services
  • Offer non-HIV healthcare services to those who test negative (as an incentive to testing), eg, free treatment for conditions other than HIV, including STIs
  • Re-examine the relative contributions of non-sexual and sexual infection routes for HIV, which must vary considerably from country to country, even within countries
  • Re-integrate HIV clinics and services into other health facilities, getting rid of expensive parallel HIV-specific structures
  • Distribute funding at a level closer to people on the ground, such as HIV positive people and those providing services
  • Re-direct some of the remaining funding to improving safety in certain service areas, eg, maternal health
  • ‘No blame’ investigations into serious outbreaks, especially among those whose risk should be low, eg, maternal health beneficiaries, virgins, infants, etc
  • Drop failing programs, such as abstinence-only and other behavioral programs that are aimed solely at sexual behavior
  • Listen to leaders who are calling for positive change, for things to be done differently, for a re-think of some of the strategies that have been failing for a long time

Big reductions in HIV funding could be used as an opportunity to make positive changes in the way the remaining funding is spent, and allow each dollar to go much further. Country leaders need to think differently, rather than chaining themselves to strategies that have been failing for years. Massive HIV NGOs and other institutions are too far removed from individual epidemics to be able to see differences between countries and within countries.

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

Mandatory HIV Tests: Shouldn’t Zambians Decide?


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

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

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

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

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

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

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

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

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

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

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

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

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

America’s Other Epidemic: HIV in Confederate States


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

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

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

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

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

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

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

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

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

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

Is that Guardian Article Really Racist?


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

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

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

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

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

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

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

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

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

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

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

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

The article is about The Guardian’s and its authors’ prejudices, not about Uganda, HIV or ‘Africans’. Presumably it contributes to, and also concurs with, the prejudices of Guardian readers, what they expect and perhaps enjoy reading about HIV, and sexual behavior in ‘Africa’.

The article does not draw attention to the fact that the health workers (ostensibly, those purveyors of (institutionalized) stigma and discrimination) make no mention of unsafe healthcare, ‘informal’ or unofficial healthcare, traditional healthcare and similar practices, cosmetic practices (such as tattooing) and others that could, however inadvertently, result in exposure to HIV contaminated blood.

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

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

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

The Deep Racism of Pathologizing Sex


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

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

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

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

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

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

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

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

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

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

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

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

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

Voice of America: Masters of Clickbait


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

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

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

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

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

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

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

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

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

Missing the Point: Bloodborne HIV in Malawian Prisons


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

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

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

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

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

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

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

 

Lisbon Declaration: Scare Stories about Sex Cost Lives


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

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

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

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

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

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

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

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

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

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

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

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

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