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Sidibe: I Say What’s Ethical

In 2010 a BBC article reported: “HIV has become the leading cause of death and disease among women of reproductive age worldwide”. We are told that “One of the key issues… is that up to 70% of women worldwide have been forced to have unprotected sex. UNAids says such violence against women must not be tolerated.”

UNAIDS Executive Director Michel Sidibe is quoted as saying: “By robbing them of their dignity, we are losing the opportunity to tap half the potential of mankind to achieve the Millennium Development Goals” and “Women and girls are not victims, they are the driving force that brings about social transformation”. So I assume his objection to forced sex is not just related to the risk of HIV.

But when a senior UNAIDS officer resigns after allegations of sexual harassment and assault, Sidibe weighs in with an attack on ‘whistleblowers’ who made the allegations, saying they “lack ethics and morals”. He also praised the accused official as ‘courageous’ for resigning. The official was not charged with any offence.

Even if the accused, Luiz Loures, was innocent, Sidibe seems to be attacking those who try to report instances of violence against women, protecting those who are accused, and turning a blind eye to those who abuse and pillory the ‘whistleblowers’ (who are really just people reporting a serious crime, but in a specific context, the workplace).

Sidibe has accused a former colleague who spoke out against the behavior of Luiz Loures of lying. These victims of Sidibe’s vicious attacks on anyone who dares to criticize UNAIDS are, effectively, accused of biting the hand that feeds them, a typical response of institutionally sexist institutions that have managed to repress criticism of this kind of behavior for decades.

But these matters have gone way past institutional sexism. Sidibe’s intention is clearly to bully and threaten anyone who wants to work for UNAIDS, but would object to being sexually assaulted, and would report it and fight it.

“We know there are people taking their golden handshake from us here and knowing that they have a job and then attacking us. We know all about that. We know every single thing. Time will come for everything. When I hear anything about abuse of our assets, abuse of our things, I ask for investigation. Maybe these investigations are going on.”

UNAIDS has produced a 5 point plan “to prevent and address all forms of harassment for greater accountability and transparency”, the second point of which is: “an open platform will be created for staff to report on harassment, abuse of authority or unethical behaviour within the organization”. But it sounds very much like those who report such things would ‘lack ethics and morals’, in Sidibe’s view.

It seems clear enough that Sidibe is more concerned about protecting UNAIDS funding, the institution itself and the top jobs than about fighting harassment and forced sex. But I don’t think it’s possible to reconcile the seemingly contradictory positions Sidibe is taking. On the one hand he defends women “forced to have unprotected sex”; on the other he attacks those raising concerns about serious sexual misconduct.

New reports of HIV outbreaks from unsafe healthcare in India and Pakistan

The outbreaks

India: On 5 February 2018, newspapers reported a nosocomial HIV outbreak in Unnao after multiple HIV-positive tests at health camps on 24-27 January. Many of the infected reported injections from a quack.[1] As of 10 February, 75 HIV infections have been reported in the outbreak, including at least 6 children; testing continues[2].

Pakistan: On 15 February 2018, the Daily Pakistan reported 22 identified HIV infections in Kot Momin. The article reports speculation that treatments by a quack doctor spread HIV.[3]

Director General of India’s National AIDS Control Organization (NACO) misleads and stigmatizes

After a team from India’s National AIDS Control Organization (NACO) visited Unnao on 7 February, the NACO Director, Sanjeeva Kumar said: “The virus can’t survive in the sun beyond a minute, so while a contaminated syringe may have caused stray infections, it cannot lead to a spurt in HIV cases.”

The Director’s statement is dead wrong and dangerous in three ways:

(a) The virus survives for hours in the open air, even when dry (see references at:

(b) The comment ignores investigated outbreaks in Russia, Romania, Libya, etc (see references at:

(c) The NACO’s Director’s comments stigmatize any resident of Unnao who speaks out to say they have an HIV infection from health care — stigmatizing them with suspicion they are promiscuous. Was it the intent of the Director to stigmatize and thereby silence people who might speak out about HIV from healthcare?

Government of Pakistan promises a thorough investigation

Quote from Urdu Point, 17 February 2018:[5] “Punjab Health Minister Khawaja Imran Nazir has said that emergency steps have been taken to control increasing cases of HIV Aids and Hepatitis in and around Kot Imrana near Kotmomin on the directions of Chief Minister Punjab Muhammad Shehbaz Sharif.”

“During his visit to a medical camp set up at the village for collection of blood samples of the area people, the minister said that thousand of samples had been sent to laboratory so far and the report would be received on Feb 20. He said that after receiving of the reports, the affected people would be provided free-of-cost treatment while a well-equipped laboratory for HIV and Hepatitis would be functional at THQ Kotmomin within two weeks.”


1. Unnao HIV cases: chief medical officer got alert in July but didn’t act. NYOOZ, 11 February 2018. Available at:–chief-medical-officer-got-alert-in-july-but-didnt-act/ (accessed 21 February 2018).

2. Williams H. Fake doctor infects 75 Indian patients with HIV. World Report Now, 10 February 2018. Available at: (accessed 21 February 2018).

3. Rehman D. The shocking reason AIDS is spreading in this Pakistani village for last 15 years. Daily Pakistan 15 February 2018. Available at: (accessed 21 February 2018).

4. Kaul R. Report on Unnao HIV cases: Migrant population unprotected sex among main causes. Hindustan Times, 18 February 2018. Available at:  (accessed 18 February 2018).

5. Shabbir F. Punjab health minister for provision of better health facilities in Kot Momin. Urdu Point, 17 February 2018. Available at: (accessed 21 February 2018).

Breaking the silence: asking KfW what it’s doing about HIV from healthcare

In 2011, Grimm and Class[1] urged Germany’s Development Bank (KfW) to pay attention to evidence “an important share of new infections in high prevalence settings occurs through blood exposures in formal and informal healthcare,” and called for “interventions targeted to strengthening the health care system in general and infection control in particular.”

How has KfW responded? Helmut Jager, a medical doctor, initiated an email exchange with KfW to ask just that. He documents the dialogue on his website[2] (for those who can’t read German, here’s a translation tool:

Questions to KfW on 22 December 2017:

What conclusions did KFW 2012 draw from the analysis of the authors Grimm and Class of 2011?

To your knowledge, have there been epidemiological studies on HIV outbreaks ever since that time…?

What measures does KfW support to prevent iatrogenic and nosocomial infections (especially hepatitis C and HIV)?

Answer by Patrick Rudolph, KfW, Sector Policy Unit Health & Social Protection, on 19 January 2018:

… thank you for your interest in the position and commitment of KfW Entwicklungsbank in the field of infection prevention.

… The key factors for the direction and design of such [HIV] projects are therefore the partner’s sector strategy considerations and the corresponding guidelines of the Federal Government (including the strategy for the control of HIV, hepatitis B and C and other sexually transmitted infections).

We support… a differentiated, demand-oriented and multisectoral approach to HIV prevention depending on the specific micro-epidemiological constellations. This may include measures to prevent both sexual and iatrogenic infections… [I]n South Africa – currently the only country in which the fight against HIV is the focus of German development cooperation in the health sector – the focus is clearly on preventing the sexual transmission of the pathogen…

In response, Dr Jager mailed these additional questions to Dr Rudolph, KfW, on 19 January 2018:

… thank you very much for your reply… Unfortunately, you have not answered my specific questions.

As early as 1990, we had already published that with regard to infections caused by the health care system, the technical equipment of blood banks was not able to solve the quantitatively much bigger problem (unnecessary indications, lack of user hygiene and improper handling of needles and syringes). The consequence of this knowledge should have been investments in the control and prevention of dangerous medical applications. This is evidently not done for the most part…

Are you really sure that…HIV proliferation in South Africa, for example, can only be explained by sexual activity? My doubts intensify among other things a study of 2014 (Kharsany 2014[3]) describing the dynamics of HIV infection of high school students in rural South Africa: 6.8% of girls were infected [including many self-reported virgins]… Where these girls infected themselves with HIV… remained unclear…

As this exchange shows, Dr Jager is challenging those who pay for HIV prevention programs to reconsider their lack of attention to HIV from unsafe healthcare. But Helmut Jager’s website is about a lot more than HIV risks in Africa; I recommend it to anyone with an interest in the history of healthcare, problems in healthcare systems, and future options.


  1. Grimm M, Class D. The fight against HIV/AIDS must be brought into balance. KFW-Development Research: views on development. No 3, 24 June 2011. Available at: (accessed 8 February 2018).
  2. Helmut Jager. AIDS in Afrika. Available at: (accessed 8 February 2018).
  3. Karsany ABM, Buthelezi TJ, Frolich JA, et al: HIV infection in high school students in rural South Africa: role of transmission among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: (accessed 9 February 2018).


Almost Positive: HIV Transmission Modes

Yet another study delves into the socio-economic, behavioral, biomedical and sexual lives of young girls, this time in Malawi. The study identifies 15 factors said to relate, directly or indirectly, to HIV transmission. But yet again, all HIV transmission is assumed to be sexual, all risks are assumed to be risks of sexual transmission, and no non-sexual risks or modes of transmission are considered. (If the link doesn’t work there is an abstract on PubMed).

One of the hopes is that those selling pre-exposure prophylaxis (PrEP) will be able to ‘target’ people thought to be most at risk of being infected. However, there is little point in targeting those who are not at risk, or even those who don’t believe they are at risk. Pre-exposure prophylaxis doesn’t work if people don’t take it frequently enough, and those who don’t believe they face any risk are unlikely to take it at all.

A scatter-gun approach would be very expensive and wouldn’t be very effective. But an approach that ‘targets’ people merely on the basis that they are sexually active is in danger of becoming a scatter-gun approach. So, on the one hand, this study (like many others) shows that most people don’t engage in the kinds of behavior said to carry a high risk of HIV infection (and many who do engage in them remain HIV negative).

But on the other hand, this study fails to acknowledge that the assumption that all risk is, directly or directly, related to sexual risk, is completely unwarranted. It is concluded that PrEP can be ‘targeted’ at women who are at risk, but that more work will need to be done to convince these women that they are at risk, and that that risk is either directly or indirectly sexual. (There’s a favorable commentary on the article on

Another study takes up the question of whether most transmission is sexual and, therefore, whether most risk is in some sense sexual risk. It does so by considering similarities among HIV genetic sequences, in order to identify possible sexual links. This study finds that only a small minority of clusters of sequences have identifiable sexual links.

This study goes on to note that there is plenty of useful data available: tens of thousands of people in African countries were followed and thousands of new infections were observed among them, but less than 10% of these were attributable to sexual transmission; also, there have been numerous HIV outbreaks outside of Africa which have been a result of unsafe healthcare (all are documented on this site). Yet, none have been investigated in Africa.

This is not such good news for PrEP, because non-sexually transmitted HIV is likely to be better addressed in other ways. But it could be great news for people in high prevalence countries. Sexual behavior and its determinants are notoriously difficult to influence, but conditions in healthcare facilities should prove more tractable. In addition, people need to be made aware of the non-sexual HIV risks so that they can avoid them, at least until conditions in healthcare facilities are improved.

Sexual Stereotyping and Relative Discomfort

In an article about a nightclub in the south of England, where couples can go one night a month so that the woman can have sex with black men while their male partner watches, Afua Hirsch is not so much concerned about the behavior of the clubbers as she is about the sexual stereotyping and racist assumptions that go with the concept of a ‘Black Man’s Fan Club’.

Someone accompanying the author objects to the fetishization of black men and women that she experiences when she goes to swingers events, elsewhere. Another woman finds that, while many black men have relationships with white women, black women tend to be ignored, by white and black men.

The article mentions sexual stereotypes about male and female black people and some of the problems this can give rise to, noting assumptions about black women having ‘voracious sexual appetites’ and the men being well endowed, dominant, having ‘better rhythm’, etc. It is suggested that even some black people, especially men, buy into this ‘hypersexuality myth’.

Without wishing to diminish the importance of highlighting this crude sexual stereotyping of ‘African’ sexuality and sexual behavior in rich countries, I’m surprised that the author doesn’t take the article in the direction of some of the, arguably, more serious consequences of this kind of ‘exceptionalism’.

For example, most HIV transmission in rich countries, such as the US, is found among men who have sex with men; a smaller proportion is a result of reusing injecting equipment by intravenous drug users. Among heterosexuals, transmission is far lower. But in high HIV prevalence African countries the bulk of transmission is among people who neither engage in male to male sex, nor inject drugs.

Extremely high rates of transmission in certain parts of sub-Saharan Africa are attributed to this same set of assumptions about ‘African’ sexuality. We are told stories of vicious, predatory males having frequent and reckless sex with women who are depicted at times as being innocent victims, but at other times as having an amazing sexual appetite.

Even articles that need not mention sexual behavior, or need not concentrate on it almost exclusively, often do so when the context is a high HIV prevalence African country. For example, a study about women being held in hospitals until bills are paid makes brief mention of a claim that someone had sex with a doctor to help cover her bills. But an entire newspaper article about the report revolved around that claim.

Another newspaper article pathologizes sexual behavior in Uganda by depicting it as the main reason for the extremely high rates of HIV transmission there. While the risk of being infected with HIV is much higher in Uganda than in most other countries, sexual behavior there is unremarkable, with a few people engaging in a lot of sex, but most people not doing so.

Another example, although there are plenty around, of sexual behavior being exceptionalized and pathologized in African countries is an article about 15 year old girls ‘selling their bodies to buy sanitary pads’. A very small number of 15 year old girls surveyed made the connection between transactional sex and sanitary pads, but the newspaper article revolves around the claim.

Afua Hirsch is right about this racial stereotyping being demeaning, insulting and completely unacceptable, whether in a predominantly white and rich country or in a non-white and poor country. It could be argued, however, that the extent of racial stereotyping about sexuality and sexual behavior in the latter contexts is far more profound, even that it is dehumanizing. Or is it less remarkable because it’s ‘over there’ and not ‘right here’?

Guardian Angles: Forced Sex to Pay Hospital Bills?

Chatham House has published a paper entitled ‘Hospital Detentions for Non-payment of Fees: A Denial of Rights and Dignity‘, the title being a good indication of what the article is about, and why a leading think-tank concerned with international affairs would research and report on such an issue.

The practice of detaining patients in the grounds of a hospital until they pay their bills, with costs continuing to rise to cover their period of detention, is widespread in developing countries. Many people in those countries see it is unremarkable, even though it infringes on the rights and threatens the health of the poorest and most vulnerable.

Relatively little research has been carried out, so the above paper suggests that its findings represent only a fraction of the severity and breath of the issue. But people can be subjected to all kinds of abuse while being held, aside from the abuse of being detained in appalling conditions.

They can be denied vital health services, forced to live in inhumane and uninhabitable surroundings, subjected to physical, verbal and emotional abuse, without access to assistance or advice, without even the realization that healthcare establishments do not have the right to detain them in the first place.

However, the details given in the Chatham House report do not justify the headline ‘Women in sub-Saharan Africa forced into sex to pay hospital bills‘. The report does list an allegation that patients have “been pressured into having sex with hospital staff in exchange for cash to help pay their bills”, also an allegation about “baby-trafficking”.

The Chatham House report links to what sounds like a very tenuous source for some of its findings, but they also refer to such items as ‘allegations’, as distinct from better supported findings.

The newspaper article also cites several questionable assertions, including one about women having sex with ‘doctors’ for a few dollars to pay off bills that amounted to thousands of dollars, but without flagging up the potentially low credibility of the source.

The newspaper article fits into a pattern of tabloid-style articles citing sources that ostensibly support their title and following assertions; yet, when you look at their sources, these turn out to give little or no support whatsoever. It’s as if the article was published because it could say what the editor wanted to publish, rather than report what the journalist found.

For example, an earlier article from the same newspaper about giving aid in the form of cash transfers is written as if this was found to be one of the most effective ways of providing assistance, but citing a report that came to the opposite conclusion.

The author of the hospital detentions article recently wrote about HIV in the Himalayas, saying that she found that it was all the fault of the men, and that the women just had to put up with it. The men were ‘migrant workers’, who ‘lied’ about how they could have been exposed to HIV, and the woman remained silent, we are told.

And another article in that newspaper blames a rise in HIV transmission on ‘dating apps’, because ‘every app is a dating app’, according to the title. Perhaps this is an instance of what the New York Times refers to as ‘techno-moral’ panic, which can take anything currently fashionable, ‘cyberporn’ in the 90s, chat-rooms not long after that, sexting, online predators, etc, and vent their indignation.

Remarkably, the article about dating apps purported to be about HIV in Pakistan, which is in the lowest quintile for HIV prevalence, globally. Although newspapers cling to the view that HIV is almost always a result of ‘unsafe’ sex, in Pakistan (and most other countries) there is ample evidence that there have been outbreaks caused by unsafe healthcare in some of the highest prevalence areas, as well as in some low prevalence countries (Pakistan, Cambodia, etc).

These journalist are happy to wallow in their favorite fantasies about ‘African’ sexual behavior, dating apps, transactional sex, trafficking and the like, almost as if they have to make up the story before an even less reliable source does so.

At the same time, they distract attention from much more serious, but far less media friendly issues, without contributing anything to the problems that they claim to be drawing attention to in the first place, at least by highlighting topics that have been missed so far, but are in serious need of attention.

‘African’ Sexuality: Colonial Trope or New Racism?

An article entitled ‘Colonial tropes and HIV/AIDS in Africa: sex, disease and race’ discusses the “idea of Africa as a place where health and general well-being are determined by culturally (and to a degree racially) dictated modes of sexual behaviour that fall well outside of the ‘ordinary’”. It raises some welcome questions about the claim that HIV is almost all caused by heterosexual behavior, but only in ‘Africa’.

The authors continue: “By analysing historical responses to these two pandemics [syphilis and other STIs on the one hand and HIV on the other], we demonstrate an arguably unbroken outsider perception of African sexuality, based largely on colonial-era tropes, that portrays African people as over-sexed, uncontrolled in their appetites, promiscuous, impervious to risk and thus agents of their own misfortune.”

This blog, and a small number of people writing about HIV in African countries, share Flint and Hewett’s disgust for “the promulgation of the European idea of African men as over-sexed and, by implication, predatory and dangerous and African women as over-sexed, promiscuous and shameless”. But the HIV bigwigs do not apologize for institutionalizing such prejudices, and never have.

While Thabo Mbeki was disingenuous to claim that HIV does not cause AIDS, Flint and Hewitt support his claim that “the outsider view of Africans remains one of people who are ‘diseased, corrupt, violent, amoral [and] sexually depraved’”. The HIV industry has a tendency to brand anything they see as questioning their rigid stance as ‘denialist’. Mbeki’s questions remain unanswered, perhaps unanswerable, by an industry that refuses to apply scientific methods in a region where the overwhelming majority of HIV positive people live.

Flint and Hewitt continue: “HIV/AIDS discourse can be seen to have slotted into an existing colonial narrative of the mysterious, unknowable and, above all, different, that was primed to accept the notion of HIV/AIDS in sub-Saharan Africa as a ‘disease of choice’ (with corresponding notions as to combating this perceived choice) – in remarkable contrast to ideas as to HIV/AIDS epidemiology and prevention outside the continent” [my emphasis].

The industry had to tone down their notions of ‘good AIDS/bad AIDS’ in western countries; fashions change (or ‘are changed’). But it was (almost) all ‘bad AIDS’ in ‘African’ countries, all someone’s own fault, all ‘avoidable’, if people would just follow advice to abstain, be faithful, avoid ‘traditional’ practices, embrace western style healthcare (albeit without western standards of safety, hygiene, funding or staffing).

The attitude towards HIV in ‘African’ countries was especially reinforced by massive sources of funding, such as PEPFAR, “a programme influenced by and largely delegated to faith-based organisations, which engendered it, at times, with something of a crusading missionary outlook. Its emphasis on abstinence and fidelity suggested strongly that each person was broadly responsible for their own individual ‘salvation’: to be infected with HIV implied moral slippage”.

Flint and Hewitt have squeezed a lot into a paper that covers so many issues, spread over a long period. However, I think they have neglected a few things that might have altered their conclusion, considerably. Firstly, they mention (in a footnote) David Gisselquist’s contention that the HIV pandemic could not have been caused by sexual behavior alone, and that unsafe healthcare practices might explain a significant proportion, perhaps even a larger proportion than sexual behavior.

With the realization that the pandemic could not have been caused entirely by ‘African’ sexual behavior, isn’t there an immediate and urgent question about what else may have been involved? Reference is made to the preponderance of epidemiologists and other interested parties with their snouts in the trough, but the sheer weakness of the evidence for this assumed ‘African’ sexual behavior must also be examined. Epidemiologists have made it clear that they are certainly not going to revise their views and consider unsafe healthcare, or anything else.

Secondly, I would also question Flint and Hewett’s claim that the line running from colonial bigotry about sexual behavior in Africa to today’s HIV industry’s institutionalized racist narrative of the HIV pandemic is ‘unbroken’ (and they do say ‘arguably’). The vitriolic hatred shown by people writing about sexually transmitted infections, ‘African’ sexuality and many other subjects was clear enough in the late 19th and early 20th centuries, continuing up to WWII, at least. But, I would argue, things changed.

There was a phase of gradual enlightenment among writers of medical papers in the three or four decades preceding the identification of HIV as the virus responsible for AIDS. Flint and Hewitt even cite an early paper from one of those whose views were based on his own research in African countries, Richard Robert Willcox [obituary]; and there were others who brought greater humanity to ‘colonial’ medicine, which had previously been viewed as just another instrument of control. One example from Willcox will have to suffice for now.

Far from blaming STIs entirely on those who contracted them and transmitted them, Willcox and some of his contemporaries wrote that there are promiscuous people everywhere, and that STIs are mainly found among promiscuous people. But they also made it clear that the majority of people are not promiscuous; several of them might even have admitted that people in Africa were no more likely to be promiscuous than people elsewhere, which is anathema to the HIV industry.

Thirdly, Flint and Hewitt don’t mention that many earlier estimates of diseases, assumed to be sexually transmitted, were distorted by the inability to distinguish non-sexually transmitted yaws and other diseases from syphilis. Figures purporting to show massive levels of endemic syphilis were not just exaggerated by the eugenicists, they were also empirically incorrect. Willcox knew that, as did many of his contemporaries.

Outbreaks of STIs could also be explained by poor treatment programs, insanitary living conditions, labor conditions (especially in mines, armies, etc), resistance to medication, shortages in supplies, unsafe conditions in healthcare facilities, changes in epidemic patterns, lack of skills among personnel involved, shortages of skilled personnel, etc. Outbreaks of HIV could also be explained by such factors, if only more epidemiologists would accept that there is no disease that has a single cause, a cause entirely isolated from all other determinants of health, and that this unprecedented circumstance can only be found in certain African countries (a fifth of ‘Africans’ live in a region where HIV positive people make up 0.06% of the population).

Numerous factors involved in STI epidemics, only a some of which are mentioned above, were recognized by many pre-HIV era writers. Therefore, those blaming disease outbreaks on ‘promiscuity’ and other ‘African’ behaviors, were bigots, not badly informed commentators. Some time after WWII, ‘colonial’ views about ‘African’ sexual behavior, at least in medical literature, became less common. It took a few decades, of course. But by the 1980s, when AIDS was recognized as a syndrome and HIV was identified as the cause, unbigoted views were frequently expressed about STIs and ‘Africans’.

The extreme views of today’s HIV industry are not, I would argue, a clear continuation of colonial bigotry. Following three to four decades of increasing scientific rigor (and decreasing institutional racism), the emerging HIV industry of the 1980s had to develop its own form of racism. Many of the earliest proponents had little or no connection with the colonial past, although they adopted several of its more egregious ‘tropes’, being compatible with some of the extreme political and social attitudes also emerging at the time.

It’s the Truth, Bill, But Not as We Know It

Aid given in cash improves health and spurs school attendance, say researchers“, according to a title in the English Guardian. “Foreign aid in the form of cash transfers with no strings attached can improve health and increase school attendance, a study has found”, claims the article. Yet, the conclusion of the study is “The evidence on the relative effectiveness of UCTs [unconditional cash transfers] and CCTs [conditional cash transfers] remains very uncertain“.

The author, Hannah Summers, has been mentioned in a blog post here on the subject of racism, HIV and pathologizing sex, and then in a double take on the same set of issues. On the subject of cash transfers, she writes as if her job, or her newspaper’s future, depend on spinning this hyped strategy, which has been claimed to reduce poverty, influence behavior, improve health, and just about everything desirable you can think of.

No mention is made in the Guardian about quality of evidence gathered by the study, which, in this instance, is astonishing: “Of the seven prioritised primary outcomes, the body of evidence for one outcome was of moderate quality, for three outcomes of low quality, for two outcomes of very low quality, and for one outcome, there was no evidence at all.”

This is not to say that handing out money to poor people had no discernable benefits. People with more money can, and often do increase spending on things like food, medicine, education, living conditions and a better environment (if cash transfers were ever to reach such dizzy heights).

So it is no big surprise that people with more money, spending more on the above, will have fewer illnesses, improved food security, and perhaps dietary diversity, school attendance, etc. Nor is it a surprise that these improvements can lead to other improvements, given time and persistence.

But is it necessary to carry out 21 studies, involving over a million participants and over 30,000 households to know that poor people need money, and that having more money will have health, education, social, environmental and other benefits?

Is Summers entitled to claim that: “a review published this week flies in the face of criticism from the anti-aid brigade, showing that cash handouts have measurable benefits for some of the world’s poorest people.” Is someone ‘anti-aid’ because they question her spin on this charade?

At times, cash transfers look like a form of pimping. International NGOs and other recipients of funding for cash transfers take a big slice for themselves. Academics get grants for the inevitable studies, some consultants and experts depend on this kind of work for much of their (considerable) income, lots of well paid people are well paid by these ‘initiatives’.

Just in case the similarity to pimping is not clear, cash transfers have been used to induce people, mainly women and girls, to have less sex, to only engage in protected sex, to go to school (said to reduce sex, or ‘unsafe’ sex), etc. If paying for sex is, at least in part, an attempt to control a woman’s sexual or reproductive choices, then so is paying for chastity.

If aid programs in their current forms are working, and need to be expanded, particularly certain types of aid program, why lie about the findings of a systematic review that explicitly questions conditional and unconditional cash transfers, and why would the English Guardian publish this obvious perversion of the findings of a Cochrane Review?

The Story is Father to the Author

The story of ‘How HIV found its way to a remote corner of the Himalayas‘ is related in an article in the English Guardian. It was male economic migrants who went to India and “returned home with a very different legacy to the one [they] anticipated”, infecting their partners, who then had children born with the virus. (But things are now improving because of the actions of the female victims.)

Here’s a comment on an ‘interview’ with one of the males who went to India to work: “Like many other men interviewed in Achham, Sarpa has a well-rehearsed story that explains how he believes he contracted HIV, but it does not involve any sex workers, whom researchers believe are the primary source of migrants’ HIV infections.”

Journalist Kate Hodal doesn’t bother telling us how Sarpa says he was infected, preferring instead to believe the testimony of ‘researchers’. How these researchers know that Sarpa is a liar, along with all the other people they have interviewed (and disbelieved), is anyone’s guess. Perhaps they have some independent explanation or account of the HIV risks that people face in India?

While Sarpa speaks “coolly”, his wife Sita “has had to accept the likelihood [Sarpa] visited Indian brothels”, indicating all this with a shake of her head.

Hodal is clearly something of a psychic, who can know that while Sarpa lies, Sita tells the truth, but without uttering it. Hodal also knows that the opinion of researchers about HIV risks is of more value than the self-reported accounts of people who are infected, or who may become infected.

Meanwhile in Canada, journalist Ashifa Kassam writes about a pop-up restaurant run by HIV positive people. Far from pointing the finger at people with HIV, the article is about ‘challenging stigma’. The words of those interviewed are quoted, and their honesty is not in question.

Population figures, numbers of people living with HIV, prevalence, even the breakdown by gender of those infected, are not vastly different in Canada and Nepal. Although Nepal’s epidemic is usually described as ‘concentrated’, in contrast to Canada’s ‘low-level’ epidemic, the two are remarkably similar in some ways.

In contrast, in Canada, the vast majority of people are infected with HIV through unprotected, receptive anal sex and injecting drug use. But neither of those routes are thought to be so common in Nepal.

However, there is a huge difference in the way HIV in Nepal and Canada are viewed by the media. In Canada, those with HIV are wholeheartedly encouraged to continue their fight against stigma. But in Nepal, the journalist writes something she may have believed before she left her desk: HIV is ‘spread’ by promiscuous men, to unwitting women and children.

HIV positive Canadians can speak for themselves, and are not required to explain or justify their status. But Nepalese men need journalists and researchers to call them out on their lies about how they were infected; and Nepalese women need the same intermediaries to identify them as victims, unable to name the aggressors, or to speculate about how their partners became infected.

HIV and Sex: Fallacy of the Single Cause

The four Kenyan counties of Kisumu, Homa Bay, Siaya and Migori that I mentioned in my last blog post have been in the news following the rerun of the presidential elections on Thursday 26 October. Voting in these four counties was suspended at an early stage and scheduled to resume on Saturday 28, but they did not go ahead.

The result of the presidential elections held in August was disputed in court, hence the rerun. But the opposition leader, Raila Odinga, later called for the elections to be boycotted, and turnout has been very low. The four counties in question are home to the majority of Odinga’s own Luo tribe, and a large proportion of people who might vote for him as president.

Astoundingly, one third of all of Kenya’s 1.6m HIV positive people live in these four counties, even though only about one tenth of Kenyans live there. These counties make up the bulk of the former Nyanza Province, in the southeast. In the blog post before that I wrote about a contrasting area, where 0.2% of HIV positive people live: Mandera, Garissa and Wajir, the former northwestern province, with a population of about 1.6m (3.5% of Kenya’s population).

In the earlier of these two posts I speculated that HIV prevalence in the northeastern counties may have remained low because of the geographical isolation of the area. Few roads go there, infrastructure is underdeveloped, health services are few and far between, and usage of health services tends to be low. Quality of health services is also likely to be low, but less harm can result if most people stay away from facilities.

In the southwest, where infrastructure is a bit better, usage of health services is higher. This means that a lot more people are being exposed to potentially unsafe healthcare. Over 4m people live in 10,200 km2, compared to the 1.6m people in the northeast, an area of 127,300 km2. Population density can be lower than 10/km2 in the northeast and as high as 460/km2 in the southwest.

Variations in sexual behavior don’t correlate very well with variations in HIV prevalence or distribution, so it can’t be the single or simple cause of HIV transmission. UNAIDS and other establishments involved in HIV programming claim that 80-90% of HIV transmission in high prevalence African countries is due to ‘unsafe’ sexual behavior, but they have never been able to demonstrate how such a claim could be true, or even plausible.

However, it could be argued that variation in exposure to potentially unsafe healthcare practices correlates much better with HIV transmission. Both areas are isolated politically, and have been for many decades. Low usage of health facilities and social services (and low availability) seems to be a consequence of the political isolation experienced by the northwest. It is home to many of Kenya’s ethnic Somalis, a piece of land that was formerly part of Somalia.

Down in the southwest, the politically isolated Luo population experienced a certain amount of growth and prosperity after independence, especially during the explosion in the population of Nile Perch in Lake Victoria. People with a bit more money are likely to spend some of that money on healthcare. But if that healthcare is not of high quality, is not safe, this might explain why wealthier people in high prevalence African countries tend to be more likely to be infected with HIV than poorer people.

These two geographical areas have certain things in common: they are overwhelmingly populated by one ethnic group, and have both sought to distance themselves from the rest of Kenya; there has even been talk of complete political separation. But there must also be something very different about the two areas that explains why the HIV burden is over 160 times higher in the southwest than it is in the northeast.

Search for ‘sexual reductionism’ on Google and you’ll come across a discussion about a Vermeer exhibition at the New York Metropolitan Museum of Art. This will give you some idea of how current HIV epidemiology seems to proceed. Apparently the texts accompanying the paintings treat every detail of the art works as being about sex.

For UNAIDS, variation in HIV prevalence is all about sex: poor people sell sex, rich people buy sex, as do employed people, women are more vulnerable to sexual exposure than men, men are more promiscuous, sexual mores are different in Muslim communities, etc. But an alternative explanation is that variation in access to potentially unsafe healthcare facilities can better account for variation in HIV prevalence within and between geographical areas.

The history of the isolation of the southwest and northeast counties of Kenya from much of the rest of the country, political, geographical, ethnic and other forms of separation, is a long and complex one. But so too is the history of the HIV epidemic, from its origins in equatorial Africa to its global spread, and the multiple causal factors that resulted in hyperendemic levels in some countries (and within some countries), but low levels in others.