Although a Journal of the International AIDS Society (JIAS) paper, which ostensibly analyses Modes of Transmission (MoT) data and reports, has been through some kind of peer review process, the term ‘systematic’ in the title is misleading. In fact the review is highly selective. The phenomena of HIV infection through unsafe healthcare, traditional and cosmetic practices have been left out completely. This is despite the ready availability of relevant and up to date papers about these phenomena.
The Don’t Get Stuck With HIV website is a repository for many relevant materials. David Gisselquist also made a paper available last year that they have completely ignored, entitled ‘UNAIDS’ Modes of Transmission Model Misinforms HIV Prevention Efforts in Africa’s Generalized Epidemics‘. The bibliography therein should be very useful for anyone who wishes to carry out a systematic review in the future.
The JIAS study mentions recommendations from a 2012 set of guidelines produced by an MoT ‘study group’ and one of them recommends to “Adopt a bottom-up approach, that is, an approach that ensures that sufficient data is available to parameterize the model before making changes to tailor the MOT to more finely represent the local setting”.
The fact that no data has ever been collected by MoT studies for non-sexual HIV transmission may explain why such modes of transmission are ignored by the JIAS study. But it doesn’t explain why non-sexual transmission receives so little attention in the HIV literature as a whole, aside from peremptory denial of its existence.
Gisselquist recently pointed out some of the most glaring flaws in the MoT methodology in a brief blog post. But even the JIAS paper itself unearths some remaining flaws that make one wonder why such a weak and fragile tool should still be used after about a decade of demonstrations of its uselessness.
Ironically, MoT tools were supposed to contribute to UNAIDS’ ‘Know Your Epidemic, Know Your Response’ strategy. This strategy, like all UNAIDS strategies, is based on the assumption that almost all HIV transmission in African countries is a result of heterosexual transmission. That means that the majority of people in high prevalence countries are said to be ‘at risk’, either of becoming infected or of infecting others. So every African HIV epidemic looks pretty much the same to UNAIDS because of the built in assumptions of their various ‘tools’.
Therefore, a strategy for ‘targeting’ those most at risk ends up not targeting anyone; HIV interventions must aim to cover entire populations. Aside from being a waste of money and time, as well as stigmatizing the most affected populations, UNAIDS have failed to account for the bulk of transmissions in high prevalence countries. The two decade old, phenomenally expensive institution throws up its hands and says that the majority of people at risk of being infected are people who fall into ‘low risk’ categories.
Despite scratching the surface of the Modes of Transmission Model and finding that that’s all there is to it, the JIAS paper concludes that some aspects of it need to be ‘revised’. Which is even more misleading than calling the paper a ‘systematic’ review. But if UNAIDS have achieved anything in the last two decades it is in showing that a garbage in garbage out strategy really does work, and may continue to attract funding for another 20 years, at least. I wonder how many of the authors of the paper will end up working for UNAIDS, if they haven’t already done so.