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Category Archives: institutional racism

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.

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.

UNAIDS: Still Chipping the Bank


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

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

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

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

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

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

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

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

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

HIV: A Rich Seam in a Long Abandoned Mine?


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

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

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

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

So, how far have we moved on 80 years after the Eugenics Review quote, above? Here’s Catherine Hankins, from the Amsterdam Institute for Global Health and Development (formerly a senior officer in UNAIDS):

As Hankins surmises, in some cultures what you do with your sexual partners over time is different. In the West we tend to be serially monogamous.

In Africa, if you’ve had sex with someone at some point, the door isn’t considered closed on picking up on that relationship again.

“Take a middle-class African businessman. He has had five women – nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a ‘deuxième bureau’ – a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.

“Within a year he may have infected four other women. Now, if I’ve had five sexual partners and catch HIV from the fifth, as a western woman I’m unlikely to return to the other four and infect them!”

You might object that it is unfair to criticize what is clearly just an opinion, however ‘expert’. But policy is based on such opinions, HIV programs are guided by them, enormous amounts of money are spent (entirely in vain) on them. Worse still, the scientific data so assiduously collected shows that Hankins is as wrong as the eugenicists. Ostensibly, at least, Hankins was responding to scientific findings, published in a scientific journal, not to someone’s opinion.

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

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

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

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

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

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.

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.