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WHO to Warn About Unsafe Healthcare Transmitted Hepatitis, but not HIV?

UNAIDS, WHO, CDC and other institutions continue their insistence that HIV is almost always transmitted through heterosexual sex in African countries (though nowhere else), and that unsafe healthcare, cosmetic and traditional practices play a vanishingly small and declining role in transmission.

It was suggested to me recently by someone who questions the above views that these well funded institutions will eventually have to change their tune. However, he felt that they would not admit that they are wrong, or that they have known since the 1980s about the risks posed by unsafe healthcare and other non-sexual HIV transmission routes.

Perhaps hepatitis C is the opportunity needed? The WHO is now warning people about the dangers of infection through unsafe blood, medical injections and sharing of injecting equipment. They are also recommending the use of injecting equipment that cannot be reused, rather than equipment that should not be reused, but frequently is.

Unfortunately, the WHO is not very explicit about the problem: there are many health professionals who are unaware about the risks of reusing skin piercing equipment, especially injecting equipment. These health professionals do not warn their patients because they are unaware that they should not reuse syringes, needles, even multi-dose vials that may have become contaminated.

People may be surprised that there are health professionals who are unaware of these risks, or that they take these risks even if they are aware of them. But every year there are cases of infectious, even deadly diseases, being transmitted to patients through careless use of skin piercing equipment. Tens of thousands of people are put at risk, and that’s just in wealthy countries.

As for poor countries, especially sub-Saharan African countries, where the highest rates of HIV are to be found, no one knows how many people have been put at risk, how many have been infected with hepatitis, HIV or other blood borne viruses, or how many are still at risk. People are not being made aware of the risks they face, so they can not take steps to avoid them.

The US National Institute of Allergy and Infectious Diseases (NIAID) still carries the rather limp “HIV cannot survive for very long outside of the body”, instead of warning people that they should not allow the blood of another person enter their bloodstream. It is irrelevant how long these viruses survive; people need to know that contaminated blood may be entering their bloodstream so that they can take steps to avoid this.

Unsafe healthcare, cosmetic and traditional practices carry huge risks, especially in countries where blood borne viruses such as hepatitis, HIV and others are common. People can avoid infection with these blood borne viruses by avoiding potentially unsafe healthcare, unsafe cosmetic practices, such as tattooing or body piercing, and traditional practices, such as circumcision or scarification.

Kenya’s HIV Prevention Revolution: Beating Swords into…Condoms

Kenya’s recently published ‘HIV Prevention Revolution Road Map – Count Down to 2030‘ presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country’s epidemic is.

Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned ‘King of Condoms’, with a paper crown on his head, demonstrating to the country’s first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don’t see that as an instance of crass infantilization? Perhaps they don’t find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed ‘Modes of Transmission’ spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn’t we start collecting empirical data to guide future efforts?

Kenya: Needle Exchange Programs Could Save Lives

Despite the success of needle exchange and other harm reduction programs around the world, there people and institutions who still reject them. Even though injection drug use is said to contribute a relatively small proportion of HIV infections in Kenya, apparently some community and religious groups don’t always wish to support them. Perhaps they do not understand harm reduction?

Canada has been particularly open to needle exchange and other programs, and the view that “Drug users shouldn’t be given clean needles…it only encourages them” is a minority view now, thankfully. If needle exchange reduces transmission of HIV and hepatitis, it must be encouraged. While it may not cut injection drug use directly, it provides a means of reaching out to users in a meaningful way.

Persecuting durg users and suspected drug users, searching and questioning them, using possession of syringes as a reason for arresting them and confiscating their injecting equipment, do not ultimately result in a reduction in injecting drug use. Worse still, these actions result in users facing potentially more dangerous conditions, as well as increasing syringes and needle reuse.

Community and religious groups may be influenced by a hangover from the Bush era. Bush had a sort of ‘victorian’ influence; if he believed something, no matter how stupid, his supporters (sort of hard to believe he had them, but he must have) would believe the same thing. This is especially true of his supporters who were in receipt of US funding for their activities.

The contribution of prison populations to the HIV epidemic in Kenya is also said to be high. Even Canada, the US and Australia don’t have a needle exchange program in prisons, but it would be wise for Kenya to establish where infections are coming from among prisoners.

Aside from the copious innuendo about what men do in prisons, male to male sex is likely to be an issue in a country where it can land you in prison. Prisoners must face other risks, too. Injection drug use is one possibility, but also perhaps tattoos, body percing, blood oaths, traditional practices occur in prisons? Even sharing razors and other sharp objects carries some risk.

Kenya’s Modes of Transmission Survey is not a reliable means of estimating the combined contribution of several groups, such as injection drug users and prison populations. People who fall into these groups may face a high risk of being infected, yet few intervention programs are currently aimed at them.

Needle exchange programs would be a good start and may help to launch other programs, such as opioid replacement therapy, in the long run. But other programs addressing prisoners, men who have sex with men, sex workers and others could address between 20 and 30% of HIV transmission, which is a very substantial figure.

Too many African countries have been swayed by Western prudishness about sexual behavior in their approach to HIV. They have adopted some of the homophobia, xenophobia and other prejudices on which various wars on ‘terror’, ‘drugs’ and the like have been based. This has not led to rapid reductions in HIV transmission; so it’s time for a change.

The Only Certainty About Unsafe Healthcare and HIV is Ignorance About It

An article by Ndebele, Ruzario and Gutsire-Zinyama, who work for the Medical Research Council of Zimbabwe, claims to dismiss the ‘wait and wipe’ finding, which came from circumcision studies carried out in Africa. This refers to the finding that men who waited at least 10 minutes after coitus and used a dry cloth to wipe their genitals were far less likely to be infected with HIV than both circumcised and uncircumcised men who did not follow this procedure.

What is most extraordinary about this finding is that it has been feebly denied by some, but ignored by far more; in contrast, the findings about a rather weak association between circumcision and HIV transmission was used to push an extremely aggressive, well funded and loudly publicized program to circumcise as many African males, both teenagers and children, as possible.

One should no longer be surprised when researchers embrace the results they expected, while at the same time distancing themselves from those they don’t expect, and certainly don’t want. The ‘wait and wipe’ finding was presented at a conference some time back and was covered by US media. But it never received the attention, or subsequent funding, that mass male circumcision programs received.

So, seven years after those hyped mass male circumcision programs started, and a claimed several million men and boys circumcised under the programs, no further research appears to have been done into this interesting finding. Ndebele et al, who don’t seem aware that HIV prevalence in Zimbabwe is higher among circumcised men, rebuke several commentators, including myself, for suggesting that ‘wait and wipe’ could become an alternative strategy to circumcision.

What I said was that appropriate penile hygiene is a lot simpler, cheaper, safer and less invasive than mass male circumcision. The circumcision enthusiasts have encouraged people to associate circumcision with hygiene, but they have never shown that HIV transmission has anything to do with penile (or vaginal) hygiene. It simply suits their purposes that people seem ready to believe in such a connection.

So how can Ndebele et al question the findings about penile hygiene without also questioning those about mass male circumcision? And how can they not call for further research to be carried out? They accuse myself and other commentators of engaging in ‘pure speculation’, which we do engage in. But we are not the ones who collected the original data, some of which we now wish to selectively dismiss, and the rest of which we wish to use to aggressively promote circumcision programs.

So they proceed to engage in pure speculation of their own, and they seem to believe they are ‘dismissing’ arguments about the possible role of unsafe healthcare with a rhetorical question: they ask “With all the campaigns on safe needles that have been going on, where on earth can one still find health professionals using unsafe needles?” The answer is that syringe reuse is likely to occur in every high HIV prevalence African country.

Merely running a campaign about unsafe healthcare and syringe reuse does not reveal the extent of HIV transmission through these routes. Nor does running a campaign ensure that unsafe healthcare simply ceases to be an issue after a few years. No number of strategies, position papers, frameworks, roadmaps, multi-page reports, toolboxes or other pen-pushing exercises so beloved by the HIV industry will tell us the extent of non-sexual transmission of HIV through unsafe healthcare.

Nor will ‘putting unsafe healthcare on the agenda’ (no matter for how long) ensure that any meaningful changes will come about. Most people know little about non-sexually transmitted HIV and are constantly told that 80% of transmission or higher in Africa is a result of unsafe sex. Researchers rarely even mention HIV transmitted through unsafe healthcare, except to dismiss it, without evidence.

The authors argue that the results they wish to embrace are correct and that the results they wish to deny are merely a “coincidental finding”, and conclude that “there is no need to conduct further research” into the ‘wait and wipe’ finding.

This just about sums up the HIV industry’s approach to mass male circumcision. This has been a process of scrabbling about for data, any data which appears to support the program, and denying or ignoring any data which shows the program to be a hoax; all cobbled together by greedy (and probably somewhat pathological) ‘experts’, who will do anything to promote circumcision, ably supported by an institutionally racist HIV industry.

Uganda: Mystery About Effectiveness of Circumcision Against HIV

The HIV industry’s circumcision division has put a lot of effort into denying that circumcised men may feel that they can safely engage in ‘risky’ sexual behaviors. But some peer reviewed articles have found that circumcised men feel that, being circumcised, they are not at risk of sexually transmitted HIV, or that their risk really is lower as a result of being circumcised.

The problem is, how do they know how circumcised and uncircumcised men become infected? They may believe the HIV industry’s mantra about almost all HIV transmission being a result of unsafe sex in African countries, but nowhere else. But what if the HIV industry is wrong? They have never checked. They have never traced people’s partners systematically or assessed their non-sexual risks, from unsafe healthcare, traditional and cosmetic practices, they have never investigated infections that were clearly not sexually transmitted.

The industry seems to feel that the end justifies the means because HIV prevalence has turned out to be lower among circumcised men in some circumstances. But if they don’t know how some men, circumcised and uncircumcised, became infected, how do they know that circumcision protects them? If circumcision is associated with higher HIV prevalence in some countries and lower prevalence in other countries, perhaps circumcision status is irrelevant. Perhaps sexual behavior is irrelevant, the HIV industry just doesn’t know.

So millions of men are said to be lining up to be circumcised and they don’t know whether it will really protect them, whether it will increase their risk or whether it will have no effect at all. They also don’t know how safe conditions are in the clinic where the circumcision is carried out.

[For more about the ineffectiveness of Male Circumcision against HIV visit our circumcision related pages.]

Why Swaziland’s Mass Male Circumcision Program Will Fail

Apparently USAID want to spend $24.5m on a mass male circumcision program in Swaziland, aiming to circumcise 150-200k males, including infants and others who are both too young to give their consent, and to be sexually active. There are three women infected for every two men, which makes one wonder why male circumcision is seen as the best way of spending this money. But for reasons best known to themselves, USAID and other institutions really want to spend money on mass male circumcision programs, even though they are destined to fail to reduce HIV transmission to any great extent, and may even increase transmission according to their own research.

The mass male circumcision program in African countries is predicated on almost all HIV transmission being a result of ‘unsafe’ sexual behavior. However, those who do not engage in such behavior will not be protected by circumcision. Researchers collecting figures for the Demographic and Health Survey suggest that some people may not report their sexual activity, which is as true in Swaziland as it is anywhere. But knowing someone is HIV positive does not tell you how they were infected. What about partner tracing? Were their partners tested? What about their non-sexual risks, such as unsafe healthcare, cosmetic and traditional practices? These are not as thoroughly investigated as people’s ‘unsafe’ sexual behavior, but without this information we can not know how they were infected. Even sexually active people are at risk of non-sexual transmission of HIV. Mass male circumcision will fail everyone at risk of being infected with HIV through non-sexual routes.

Aside from the fact that HIV prevalence among circumcised men is not that different from prevalence among uncircumcised men, about one fifth of men and almost one third of women aged 15-49 years are already HIV positive. Exactly how were all these people infected? It’s just assumed (by the HIV industry) that they must have been infected sexually. The 5.2% of women and 2.1% of men found to be HIV positive, but who said they had never had sexual intercourse, were also likely to have been infected by some non-sexual route.

The mothers of 11 out of 50 infants found to be HIV positive were themselves HIV negative, so those infants would have been infected through some other non-sexual route, probably through unsafe healthcare. Mother to child transmission (MTCT) is acknowledged as a non-sexual mode of transmission; it is even assumed when infants and young children are infected. But given the above mentioned findings, this assumption could easily be wrong even in some cases where the mother happens to be infected.

Mass male circumcision was introduced in Swaziland in 2007, targeting HIV negative men between 15-24 years and newborn babies (though it is available to all uncircumcised men). 13.3% of men in urban areas are already circumcised and 6.2% of rural men. Why is the practice less common in rural areas? The reason for the question is that HIV prevalence is higher in urban than rural areas and it would be interesting to know if sexual practices really are substantially different, or if conditions in and access to health services, health seeking behaviors and other, non-sexual circumstances were also different. Not many people would wish to be circumcised in health facilities where practices are unsafe, where they may be infected with the very disease the operation is said to avert.

It is reported that 43% of men between 15-49 years say they want to be circumcised, compared to 54% who say they do not. Saying you want to be circumcised is not the same as actually going ahead with the operation, as various mass male circumcision programs have already found. The use of the term ‘man’ is also suspect. How many children and people in their early to mid teens will also be railroaded into agreeing? Apparently the recruiters go to schools and press-gang whole classes to turn up to be circumcised in Kenya; once a few agree, all the others are afraid to refuse.

Rather pathetically, the Demographic and Health Survey finds that “the relationship between HIV prevalence and circumcision status is not in the expected direction”, meaning that prevalence is higher among circumcised men (21.8%) than uncircumcised men (19.5%), something that has been found in many countries. To be fair, the numbers of circumcised men are not high, so it’s hard to tell if the difference on its own deserves much attention.

A good deal of other potentially useful data about circumcision was collected, but not reported in the DHS Survey. For example, people were asked their reasons for circumcision, whether tradition/religion, health/hygiene, sexual satisfaction, ease of putting on a condom, other and don’t know. I suspect most people would have had it done, voluntarily or otherwise, for traditional or religious reasons because the health/hygiene arguments had yet to be manufactured when this report was completed; the increased sexual satisfaction argument is spurious and was also added in to the repertoire more recently; ease of putting on a condom, also entirely spurious, is relatively recent; one can only imagine what ‘other’ reasons may have been given, and why someone would choose to have a circumcision without knowing the reason, unless they had given in to peer pressure.

The Global Burden of Disease Report for Swaziland finds that HIV is the top cause of premature death in 2010, accounting for 41% of years of life lost, 341 per 1,000, an increase of 1,625% on the 1990 figures. But syphilis, which stood at number 7 in 1990, accounting for 3% of years of life lost, is no longer in the top 25. It fell further than any other disease over the 20 year period. Why is an easy to transmit infection like syphilis dropping in prevalence in a population said by the HIV industry to engage in high enough levels of ‘unsafe’ sexual behavior to result in the highest HIV prevalence in the world?

The list of reasons why mass male circumcision will fail, as will any other ‘intervention’ predicated on HIV being almost entirely sexually transmitted, goes on. Many people, probably a majority, only have one sexual partner; only a few have many. Most people don’t engage in ‘higher risk’ sex, though some do. Many people ‘take precautions’, though not enough. Factors such as residence, employment status, education level and wealth quintile are often said to determine people’s sexual behavior, but they also determine their health, health seeking behavior and many other things.

Even the sexual behavior data frequently contradicts assumptions about HIV being sexually transmitted. Among women, HIV prevalence is far higher for those who have ever used condoms (42.7%) than those who have never used them (29.4%). Among men too, prevalence is higher for those who have ever used condoms (30.7%) than those who have never used them (17.6%). Condoms protect against sexually transmitted HIV, not non-sexually transmitted HIV, a subtlety apparently lost on proponents of the sexual paradigm, and mass male circumcision programs.

Despite the best efforts of the HIV industry to find one, there is no unified theory of HIV transmission. It is not all transmitted through heterosexual sex and it is not all transmitted through non-sexual routes. The problem is, we don’t know what proportion is transmitted through sex and what proportion is transmitted through non-sexual routes. Some prevention interventions may work if guided by accurate data about how people are infected with HIV, which people and where. But in the absence of that data the bulk of transmissions will remain unaddressed. Mass male circumcision programs are not even vaguely targeted and only address sexual transmission, so they are irrelevant to the majority of people.

WHO Supports Circumcision Despite What They Know About Injection Safety in Africa?

The World Health Organization’s (WHO) mass male circumcision page states that the operation reduces risk of HIV transmission from females to males (etc), and that they and UNAIDS recommend circumcision as a strategy for HIV prevention, “particularly in settings with high HIV prevalence and low levels of male circumcision”. The claimed maximization of “public health benefit” raises many questions, about compatibility with their current victim blaming and individual responsibility strategy, and also about what can be done in areas with high rates of circumcision and high rates of HIV prevalence (or do they have a policy on foreskin reconstruction?).

But the question I’d like to concentrate on is what WHO means by ‘settings’. If it refers to high HIV prevalence countries, then they must be aware that most HIV epidemics do not follow national or other geographical or political boundaries. Malawi, as mentioned in a previous blog, can be divided into three clusters, two clusters of low HIV prevalence and one of high prevalence. Only the high prevalence cluster has high rates of circumcision. Rwanda, similarly, has three clusters, two of low prevalence and one of high prevalence. Burundi has only one cluster, and that’s the capital city, where most of the country’s HIV positive people reside.

Indeed, high HIV prevalence tends to cluster in cities in most African countries, yet the vast majority of people in most high prevalence countries live in rural areas, where prevalence is often low, sometimes very low. So WHO aims to target up to 80% of males, when most of them can not be said in any useful sense to live in ‘high HIV prevalence settings’. Although HIV epidemics are heterogenous, within as well as between countries, if high prevalence settings refer to anything at all they refer to areas where access to healthcare facilities is high and levels of safety in healthcare facilities are low (for example).

It gets worse because if you look at Burundi and Rwanda’s Demographic and Health surveys (just two examples out of many) you will see that HIV prevalence is higher among Muslim men (mostly circumcised) than men of some of the other (often non-circumcising) denominations; prevalence is lower even among uncircumcised Muslims than circumcised Muslims. Other Demographic and Health Surveys show that HIV prevalence is far higher among Muslim women than among women of other denominations, not just higher than among Muslim men. So, not only does circumcision not always protect men from HIV, it may well have something to do with higher rates of transmission from men to women; this at least merits a bit of investigation, doesn’t it?

What does this have to do with WHO’s (somewhat vague) data on injection safety and healthcare safety, more broadly? Well, in a document on injection safety success stories, the WHO notes that an estimated 25 billion injections are administered annually and that an estimated 70% of them are unnecessary. The report states that “Unsafe practices and the overuse of injections can cause an estimated 32% of Hepatitis B virus, 40% of Hepatitis C virus and 5% of all new HIV (human immunodeficiency virus) infections every single year.” “At least 50% of injections were unsafe in 14 of 19 countries…for which data were available” according to another WHO report.

We don’t know what levels of injection safety are like in WHO ‘priority’ countries for mass male circumcision programs (Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe). But we may assume, in the absence of data, that high HIV prevalence countries also tend to have higher rates of HIV transmission through unsafe injections. So what is the range of ates? 10%? 20%? The rate would be very low in many Western countries, so it must be fairly high in at least some high HIV prevalence countries to average at 5%. But if we are not told how high rates are, and for which countries, how can ‘priority’ countries even weigh the benefits against the risks? How can WHO, for that matter (yet they do claim benefits, up to “3.4 million new HIV infections” to be averted by 2025, not forgetting savings of US$16.5 billion)?

The 20 million figure that WHO recommends to be circumcised only refers to medical circumcisions (and it doesn’t include children or infants, not yet anyhow), not to all those non-medical circumcisions carried out in unsterile conditions. The number of non-medical circumcisions would be many tens of millions, perhaps even over one hundred million over the course of these mass male circumcision programs (another 11 years to go). What if even just 5% of them were to be infected with HIV through unsafe practices? They won’t be receiving injections, presumably, but one would like to think that WHO approved programs would have higher standards of safety than circumcisions performed in unsterile conditions by non-medically qualified people. Alas, it is difficult to estimate rates of HIV infections through unsafe medical and traditional practices because so little effort has ever been made to collect such data.

WHO and UNAIDS are obsessed with sexual behavior, but reluctant to assess non-sexually transmitted HIV, especially via unsafe injections and unsafe healthcare in general. Yet they are willing to promote mass male circumcision programs to reduce HIV transmission when their own figures suggest that the number of people who risk being infected with HIV through these programs is likely to be far higher than even the most outlandish estimates of infections ‘averted’. Far from being a ‘distraction’ from effective HIV prevention, as some have called it, mass male circumcision programs are likely to transmit several times more infections than they could ever hope to avert.

Mass Male Circumcision: Western Sponsored Institutionalized Racism

Malawi News Agency has put out a fatuous ‘article’ about a journalist who has been duped into being circumcised in an effort to persuade others to follow his ‘example’. This reminds me that about 6 months ago I blogged about a misinformation service called Internews, connected with the rather smug Gates Foundation and the BBC. Internews boasts about being able to ensure that only ‘positive’ coverage of the US Government’s mass male circumcision program in African countries with medium to high HIV prevalence appears on African news sources.

This Malawian journalist was, apparently, persuaded also by the fact that circumcision is said to protect against human papilloma virus (HPV), although the evidence for this is even slimmer than that relating to HIV. More importantly, many African countries are already receiving assistance to vaccinate millions of Africans against HPV (currently being piloted), so why promote mass male circumcision as well? Are they afraid the HPV vaccination will not give as much protection as their promotional literature claims?

However this journalist was either too innocent, or too well paid off, to check available figures for HIV prevalence among circumcised and uncircumcised men in Malawi. In 2010 HIV prevalence was 14% among circumcised men and only 10% among uncircumcised men. This makes it look as if not being circumcised is protective. But things get a lot worse if you look at the three regions of Malawi, where HIV prevalence and circumcision are very clearly correlated:

Malawi (2)

How much clearer could this be? It is even possible to view these figures for Malawi another way. A 2013 article entitled ‘Mapping HIV clustering: a strategy for identifying populations at high risk of HIV infection in sub-Saharan Africa‘, using the same data (from the 2010 Demographic and Health Survey) identified three major HIV ‘clusters’ in Malawi. The cluster in the North and the one in the center of the country were of relatively low HIV prevalence, where circumcision rates are low. The cluster in the South of the country was of high HIV prevalence, where circumcision rates are high.

Internews and their collaborators would not wish anyone to mention this in a national newspaper, as their express aim is to ensure that only positive coverage about mass male circumcision and HIV transmission sees the light of day; or at least that those who are being told these lies and deceptions don’t know that there are things about circumcision they would be well advised to research. Reading a newspaper that has been bought off by some misinformation service is not research.

The article is full of the usual anecdotal rubbish about mass male circumcision, including some deluded victim of Internews and Co. (also a journalist) who had a problem with penetrative intercourse before being circumcised, the old chestnut about circumcision making people “clean and free of bad odours” (despite making it clear that some of these people suffering from bad odors ‘wear the same underwear for several days), sex being better, etc.

Several times the official claim about mass male circumcision is repeated, that it only ‘gives 60% protection, that people still need to use condoms’ and the usual claptrap. The article even points out that circumcision rates are high in the South and low in the other two regions. But, and this is the clever Internews bit, they don’t bother mentioning that HIV prevalence in the country is highest where circumcision is more widely practiced and lowest where circumcision is less widely practiced.

One of the biggest worries about mass male circumcision is that being circumcised only sometimes appears to be correlated with lower HIV prevalence; just as frequently it appears to be correlated with higher HIV prevalence. Given that there is no known mechanism by which circumcision could protect against HIV infection (only a handful of vague protohypotheses), these differences make it clear that there is a lot more to HIV transmission than circumcision status.

The clear message about mass male circumcision and HIV being payrolled by Internews, Gates Foundation, UNAIDS, PEPFAR and the likes is that Africans are promiscuous, reckless, ignorant and unhygienic; this kind of neo-imperialist institutionalized racism is par for the course in the HIV industry (yes, it is an industry, just like development) and would be condemned as such in most western countries (aside from the US, and perhaps the UK, apparently). So why do we find it acceptable to allow people in high HIV prevalence countries to be systematically deceived?

Avoidable HIV Infection Ignored Because of Refusal to Accept Non-Sexual Transmission

Continuing the theme of my last post, but this time using the 2011 National Antenatal Sentinel HIV & Syphilis Prevalence Survey in South Africa, I again wonder why authors of such reports insist that HIV is almost always transmitted through ‘unsafe’ sexual behavior and fail to say anything about non-sexual modes of transmission.

Disturbingly, the authors note that the “the 2011 report has shown beyond reasonable doubt that there is no significant correlation between HIV and Treponema palladium, the etiological agent for active syphilis, as co-factor for HIV infection.In the 2012 survey we have started to pilot monitoring of Herpes type 2, HHV2, which usually causes genital herpes and is transmitted primarily by direct contact with sores, most often during sexual contact.” This sentiment is echoed on three further occasions in the document.

Rather than suspecting that HIV may sometimes be transmitted through non-sexual routes, such as unsafe healthcare, unsafe cosmetic practices or unsafe traditional practices, they are looking for another sexually transmitted infection to ‘correlate’ with HIV. Why? Or, better still, why not investigate non-sexual routes? There’s plenty of evidence.

South Africa is not the only country to survey syphilis prevalence along with HIV prevalence. Uganda and Zambia also do so, with similar results. Below are radar graphs for all three countries, showing that if syphilis is a proxy for unsafe sexual behavior, HIV does not resemble syphilis very much. This is no surprise, but data continues to be collected and analyzed, before concluding that there is little or no correlation.

South Africa

HIV and Syphilis in South Africa


HIV and Syphilis in Uganda


HIV and Syphilis in Zambia

How many more years are to be wasted pretending that HIV is almost always transmitted through sexual behavior in high HIV prevalence African countries, but nowhere else? People in high HIV prevalence countries need to be made aware of the non-sexual risks they face. Health facilities, cosmetic facilities and other sites where HIV may be transmitted through contaminated blood or other bodily fluids also need to be made safer. Failing to address lack of knowledge and unsafe non-sexual practices results in an as yet unestimated number of people becoming infected with HIV; these infections are all avoidable.

South African National HIV Survey Betrays Those Facing Non-Sexual Risks

The latest South African National HIV Prevalence, Incidence and Behaviour Survey, 2012 was released recently. Much of the media coverage concentrated on things like the worrying increase in HIV prevalence compared to the last survey, which was carried out in 2008, said to be the combined result of new infections and a big increase in the number of people living longer with HIV as a result of being on antiretroviral therapy.

The report is a useful document, as far as it goes. But there isn’t even a hint that several non-sexual modes of HIV transmission could be contributing to the worst HIV epidemic in the world (in terms of number of people living with HIV, 6.4 million). This is a lot more worrying than the increase in prevalence, because failing to address non-sexual modes of transmission will result in people continuing to be infected through unsafe healthcare, unsafe cosmetic practices and unsafe traditional practices.

Underlining the clear assumption that almost all HIV transmission is a result of unsafe sexual behavior, there is a lot of attention paid to mass male circumcision programs. These are not going so well in South Africa because the majority of circumcised people chose this as a tribal rite, not because they had been hoodwinked into believing that it would save them from various diseases, HIV just being one of them. But the report fails to stress that this means most circumcised males in South Africa faced a far higher risk of being infected with a number of diseases by being circumcised in unsterile conditions.

The report also agonizes over the usual ‘behavioral determinants of HIV’, such as early sexual debut (a minority of males and females become sexually active at a young age, the vast majority don’t), ‘intergenerational’ sex (a minority, about a fifth of females do, most males don’t and this issue has been questioned recently), multiple sexual partners (also a minority do this, more males than females, although HIV prevalence is far higher among females) and condom use (increasing, but probably too low to have much impact on transmission).

However, simply ignoring the possible significance of how people respond to questions is the most arrogant, and probably the most dangerous aspect of the report. There is a list of reasons people gave for believing they would not contract HIV and a few from this list were cited in the media, triumphantly, because some people who thought they would not contract the virus were already infected. Here’s the list, with the number of people giving the response and the percentage:

Reasons for belief one would not contract HIV – number and % of cases

I have never had sex before 21,150, 11.0
I abstain from sex 21,147, 21.3
I am faithful to my partner 21,144, 32.0
I trust my partner 21,149, 22.5
I use condoms 21,146, 19.2
I know my HIV status 21,136, 9.8
I know the status of my partner 21,134, 4.4
I do not have sex with sex workers/prostitutes 21,112, 1.7
My ancestors protect me 21,070, 1.1
God protects me 21,142, 2.5
I am not at risk for HIV 21,151, 8.9
Other 21,142, 10.4

Do those carrying out the survey never, for one moment, suspect that some people might be telling the truth? Some people who have never had sex before are being told for the first time that they are HIV positive, and that it’s almost certain they were infected through some kind of unsafe sex. What efforts are made to find out how they were infected? What about those who are faithful to their partner? Is their partner tested?

The authors of the report seem to relish the term ‘evidence-based’ when referring to various different ‘interventions’ that are expected to reduce HIV transmission; when these interventions appear to fail, those who become infected, or who give inconvenient answers to survey questions, are blamed for their ‘sexual behavior’. If the researchers don’t even check how people become infected, in what way are the interventions evidence-based? If people are not believed when the answers don’t suit the researchers, why should we accept other parts of the report where the answers are in line with what the researchers expect to hear?

Assuming that HIV is almost always transmitted through ‘unsafe’ sexual behavior, regardless of all the indications that it is also transmitted through unsafe healthcare, cosmetic or traditional practices, is a betrayal of HIV positive people; it is also a betrayal of those who still risk becoming infected through such routes. These non-sexual routes urgently need to be addressed by investigating and cleaning up health centers, salons and other potential locations, and by warning patients about the dangers of being exposed to the blood and bodily fluids of other people.