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Category Archives: behavioral paradigm

Is that Guardian Article Really Racist?


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Deep Racism of Pathologizing Sex


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

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

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

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

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

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

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

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

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

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

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

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

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

Voice of America: Masters of Clickbait


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

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

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

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

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

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

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

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

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

Missing the Point: Bloodborne HIV in Malawian Prisons


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

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

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

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

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

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

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

 

Lisbon Declaration: Scare Stories about Sex Cost Lives


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

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

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

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

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

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

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

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

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

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

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

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

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

From Barefoot Doctors to Barefaced Bankers


The Oakland Institute researches and publishes about access to some of the most basic of human needs that continue to be denied to the majority of people in developing countries. These issues include land, food security and sovereignty, trade and aid. An exceptionally powerful barrier to access to these and other human needs is the World Bank and its associated institutions.

A recent report details how the WB’s ‘private sector arm’ (or is the WB merely a public sector tool of the private sector?), the International Finance Corporation, is deeply involved in extensive land grabbing projects, particularly in some of the most impoverished countries in Africa. There’s a brief article about the report, and other WB related reports, on Oakland’s site.

These landgrabs are carried out purely for profit, although descriptions of them are often padded out with talk of ‘sustainable development’ and other honeyed words. Far from benefiting anyone in poor countries, these programs squeeze massive profits from the poor through exploitation of the land for palm oil and other damaging commodities.

The few ecologies that have survived decades of colonialism and neocolonialism continue to be destroyed by institutions that claim to be ‘helping’ the poor. Populations in the countries affected become more dependent, less food secure and less healthy, communities and government, local and national, become less stable.

The current president of the World Bank, Dr Jim Yong Kim, used to be a ‘global health leader’, co-founder of Partners in Health, holding senior positions in some of the biggest names in US educational institutions (albeit some of the most neoliberal and elitist ones).

He held a senior position in the World Health Organization, contradictory as that sounds for someone who used to champion the work of Barefoot Doctors, ‘accompaniment’ and other types of community health volunteer. Indeed, it was his associations with work with the very poor that were used as arguments for his appointment to the WHO and, eventually, the World Bank.

It’s decades since the World Bank has even pretended to have anything to do with the world’s poor. It has long prioritized the ambitions of rich countries to grab land, control food production, kill off any grassroots movements, destabilize governments that their rich country management don’t like and generally promote the status quo: more for those who are already rich and powerful, never mind the exploited.

But organizations like Partners in Health have been elevated to almost cult status by the press, in papers and books and in the popular imagination. Their talk of ‘liberation theology’ (to those who have will be given more?) and frequent mentions of touchy-feely philosophers such as Michel Foucault and Paulo Freire attracts those who like a veneer of ‘ideology’ with their neoimperialism. Another founder of Partners in Health, Paul Farmer, has even been referred to as ‘a saint’ by Kim.

Perhaps this association with (currently fashionable) cultist tendencies and cult figures have been factors in Kim’s rise to president of one of the most destructive institutions in the history of rich countries’ savage profiteering in poor countries? It is very hard to find criticizm of people like Kim and Farmer, which is part of the reason for suggesting an element of cultism, of cult status.

However, there is some criticizm of Kim, given his prominence in fields beyond medicine and development. One critic even argues that Kim twisted the philosophies of several philosophers to put forward what is just a barefaced, market driven, neoliberal agenda, that he manages to sell to his adoring followers. The World Bank seem to have recognized Kim as a fellow traveler a long time ago.

There is also a powerful critique of Farmer, which adds to the impression that these guys have done very well under the status quo (thank you very much), have done everything in their power to ‘fight’ for the status quo and have become leading figures in promoting a kind of chocolate box version of activism, that you can buy and distribute among your friends on your way to the latest popular protest.

Apparently Kim was fond of urging students to study for MBAs rather than the medicine (and anthropology, don’t forget, that’s where the ideology gets a toe in the door) that he and Farmer studied. One critical account of Farmer suggests that “Farmer and Kim are…embodiments of the dark side of the spirit of 1968”. Others question the wisdom of Kim urging for action without theory, especially those who have studied Marx and Freire.

Using polite terminology such as ‘structural violence’, rather than condemning anti-poor policies wielded by the World Bank, neither will question the actions of international development institutions, or the rich country governments who profit from poverty and inequality. So neither of them are likely to have the stomach to criticize an institution that played such a shameful role in destroying any opportunity African countries had to develop themselves in the decades following independence.

Depending on how you view him, Kim appears to have come a long way from his early work in bringing healthcare to the poor. But he also showed great foresight and diplomacy in his treatment of what has become one of the principal causes of poverty, the World Bank. So who knows, perhaps he always had a penchant for banking? He and Farmer like to warn against what they term ‘immodest claims of causality’. But Freire reminds us that impeding those who would question the likes of the World Bank are themselves committing structural violence.

US, Protect Us from All Harm Reduction


Where harm reduction policies went up, hepatitis C (HCV) incidence went down, study finds’. Nothing very surprising about that, is there? Harm reduction strategies, such as free needles and syringes and substitution therapies for injecting drug users (IDU), safe healthcare, etc, reduce harm; sort of tautological, really.

But countries like the US have resisted providing support for harm reduction strategies, refused to put much money into them, and often refused to allow recipients of US donor funding to allocate money to harm reduction.

This refusal to adopt harm reduction strategies has been going on for decades, and could have reduced a lot of HIV transmission as well. The above article is about a study covering harm reduction among IDUs over a period of 25 years.

It finds that HCV infection rates remained high in two US cities and a Canadian city, but dropped in an Australian and a Dutch city. This is because harm reduction strategies were very limited in the US and Canada, but not in The Netherlands and Australia. Should I repeat that for those who continue to resist (till death…etc)?

Decades ago, perhaps even longer, objections to harm reduction strategies were based on the claim that, for example, making clean needles and syringes available would encourage use of injected drugs and even increase use, comprehensive sex education would increase unsafe sex, and the like.

Utterly ridiculous, and shown to be so time and time again. But that’s the sort of argument that conservative people (whether they would identify themselves as conservative or not), professional politicians and many religious people continue to cling to.

Some people were persuaded, perhaps for political rather than rational reasons, to drop their insistence on using these infantile arguments against harm reduction when HIV became the headline health issue, a status it still holds in many countries, but many were not.

Comparing HIV and HCV, hundreds of millions of people are infected with HCV, far more than the few tens of millions of people infected with HIV. Annual deaths from HIV in the US, which has the worst epidemic in the rich world, stand at over 12k; from HCV, the figure in 2014 was close to 20k.

HCV, unlike HIV, is curable. As with any infectious disease, treating people would reduce the number of new infections to the extent that the epidemic could be controlled, and kept at a much more manageable number (although eradication would, of course, be preferable).

But the treatment is so expensive that even most people in rich countries are not able to afford it. This was the case with HIV for a while, but big pharma still manages to make a very large profit, even after negotiating a very lucrative piece of PR about price reduction. So it seems likely that the same could be done for HCV drugs, should there ever be the political will to achieve this goal.

A combined harm reduction and cost reduction strategy would have a massive impact on HCV prevalence. Since HIV is so easily transmitted through IDU, this would at the same time address the second biggest contributor to the US HIV epidemic (the first being anal sex among men who have sex with men).

But another form of harm reduction, safe healthcare, would have an even greater impact on the HIV and the HCV pandemics. Far more people are infected lgobally with HCV through routes other than IDU, especially in high HIV prevalence countries. The highest HCV prevalence in the world is in Egypt, where it was mostly a result of unsafe healthcare.

Although the HIV politbureau of UNAIDS, WHO, CDC and others don’t like to talk about HIV transmission via unsafe healthcare in high HIV prevalence countries, except to bluntly deny it, it is likely that the rate of new infections would mysteriously drop like a stone in countries that adopt a well supported, well funded safe healthcare program.

If harm reduction strategies reduce harm, and this has been known for decades, why is there so much resistance? Skip the dumbass excuses about clean injecting equipment increasing injected drug use and comprehensive sex education increasing unsafe sex, it’s well demonstrated that the opposite is the case. So, what could UNAIDS, WHO and CDC have against HCV and HIV harm reduction strategies? Just the fact that they work?

Drugs for All Deemed More Profitable than Circumcision


Demands to roll out mass male circumcision programs, claimed to reduce HIV transmission, date back at least 20 years. Other claims about the ‘benefits’ of circumcision go back centuries. But by the time the programs had started several other interventions had been identified that have a far better claim to reduce HIV transmission.

For example, ‘test and treat’, the practice of putting everyone who tests positive for HIV on ARVs immediately, is claimed to reduce transmission to a HIV negative sexual partner by 96% or higher. (Note, 90 is something of a magic number in UNAIDSland at the moment, with their 90-90-90 strategy replacing various other magic numbers conjured up in the past.)

PrEP, the practice of giving ARVs to HIV negative people who are thought to be at risk of infection with the virus, is also claimed to reduce transmission to a HIV negative partner by 96%.

If the number of HIV positive people in the world is something around 30 million, depending on which estimates you use, and about half of them are claimed to be on ARVs already, there are still around 15 million who can benefit from ARVs. That’s worth, say, a few billion dollars.

Although a lot of those opposed to mass male circumcision don’t seem to realize this, many of those promoting circumcision are the same people who promoted behavior based programs, particularly those with an emphasis on ‘abstinence’. Those programs, although they never completely died out, were a disaster. Even the people formerly pushing them now admit that they probably had no impact on HIV transmission. But they wanted to find another source of funding to replace the vast amounts that used to go into ‘prevention’, a lot of which was spent on behavior based rubbish.

Circumcision seemed like the answer because the number of people who could be targeted for circumcision could run into hundreds of millions. Every year millions more male children would be available to keep the programs profitable.

At first the promoters claimed they were only targeting sexually active adults, but they quickly found that most of them didn’t want to be circumcised. It was much easier to recruit children and now they can turn their attention to infants.

But with test and treat, coupled with PrEP, how can the circumcision enthusiasts still claim that there is any benefit to the operation? They need to target almost the entire male population in countries where circumcision is not widely practiced. They must carry out the operation on about 75 men for every one claimed reduction in HIV transmission.

The other interventions, test and treat and PrEP, are claimed to be targeted at those most at risk. Let’s take a look at who is thought to be most at risk, and see just how many hundreds of millions of people that involves, who would need to be taking these drugs for the rest of their lives in the case of test and treat, and for as long as they are thought to be at risk for PrEP.

In western countries there are few groups who are thought to be at risk. The biggest group is men who have sex with men. The second biggest group is injecting drug users. But aside from commercial sex workers, who are given some choice in prevention options in many rich countries, there are not many others.

The picture is completely different in southern and eastern African countries, with high prevalence and/or large numbers of people infected with HIV. This article about a PrEP program in Kenya says the groups of people claimed to face the highest risk of being infected include:

  1. Discordant couples (where one partner is HIV positive and one is HIV negative)
  2. People who frequently contract sexually transmitted infections
  3. People who are said to be unable to ‘negotiate’ condom use
  4. People who frequently use post-exposure prophylaxis (a short course of ARVs for people who suspect they may have been infected, taken within 72 hours of contact)
  5. People who share injecting equipment

Out of the estimated 77,600 new infections in Kenya it is not clear how many arose among any of the listed ‘risk’ groups. High prevalence countries tend not to trace contacts, assuming that the bulk of transmissions (about 90% if you exclude infants said to have been infected by their mothers) were a result of heterosexual intercourse.

You could easily add other risks to the above list, for example (most of the following are a risk in developing countries although 7, 10 and 12 are likely to be more common in rich countries):

  1. People who have given birth in a health center/clinic
  2. People who have given birth at home, or anywhere other than in a health center/clinic
  3. People who have received birth control injections
  4. People who have had injections, blood tests, transfusions, dental care, infusions, etc
  5. People who have had operations that involved piercing the skin, major or minor (including circumcision)
  6. People who have received some forms of traditional healthcare that involved skin piercing
  7. People who use injected appearance or performance enhancers (eg botox, steroids, etc)
  8. People who get their head shaved or where skin is pierced and/or weakened by processes
  9. People who receive manicures, pedicures, etc
  10. People who have body piercings
  11. People who practice scarification and other practices
  12. People who get tattoos

Of course, with the second list, you could warn people about the risks and clean up health centers, cosmetic establishments and anywhere skin piercing occurs (the list is surprisingly long). This would seem preferable to putting almost everyone in a population on expensive drugs for many years.

But UNAIDS, CDC, WHO and other establishments object to calls to warn people about the risks they face in health and cosmetic facilities in developing countries. They warn some people from rich countries about the risks in poor countries but they refuse to warn people in poor countries.

Even concentrating on the risks listed in the Kenya article it is easy to identify many millions of people who could be said to need the $775 per annum PrEP, which is the estimated cost of the drugs alone (I don’t know what other costs there may be).

So you can see the attraction for the HIV industry. If there were only 5 million people requiring years of ARVs, for some, a lifetime of ARVs, that’s several billion dollars for Kenya alone. There are countries with higher prevalence and others with higher numbers of people infected than Kenya.

With only a few billion dollars for mass male circumcision, with its 1.3% absolute risk reduction, or even the claimed 60% relative risk reduction, drugs for the sick and the well seems like a far more lucrative strategy. Even if the benefits realized for mass male circumcision far exceed those unlikely claims, they can’t come close to the claimed benefits of test and treat and those of PrEP.

One problem is that you can’t roll out PrEP for many of the groups claimed to benefit. For example, in discordant couples the positive partner should already be receiving ARVs. People who share injecting equipment could be better served by a clean syringe and needle program. There may be other examples, where overlapping PrEP and test and treat might raise eyebrows among the more scrupulous in the industry.

And it would be perverse to give PrEP to people while they still attend clinics and other places where skin piercing procedures take place without warning them about the risks and also ensuring that those places start to abide by strict infection control regulations that people in rich countries (and rich people in poor countries) enjoy.

If PrEP and test and treat strategies are as wonderful as we are told, let’s hope they do as well in the field as they did in trials. But let’s also get rid of these silly mass male circumcision programs. We no longer have to pretend that they will reduce HIV transmission, or even pretend that that’s why they were rolled out in the first place. Worse still, the profits are orders of magnitude lower than the drug based strategies.

HIV: Cuba’s Success and Uganda’s Failure


Uganda is frequently mentioned in glowing terms in articles about HIV, especially in relation to the late 80s, 90s and early on in the 2000s. In contrast, Cuba is rarely mentioned in glowing terms, although the percentage of 15-49 year olds infected with HIV (prevalence), at 0.3%, is 23 times smaller than the same figure for Uganda, which stood at 7.1% in 2015 (all HIV figures from UNAIDS).

In fact, one could suggest that Uganda never got to grips with the epidemic. They still can’t explain why so many people, said to face a low risk of being infected with HIV, have seroconverted over the past several decades. Despite huge amounts of research, money and other resources being thrown at the country, the bulk of published research on HIV in Uganda seems to be focused on assumed sexual behavior and assumed sexually transmitted HIV.

Little or no international funding went into the HIV epidemic in Cuba. The country worked hard to research the epidemic, even before the first HIV positive person was identified there, several years before. Luckily, the country had a well developed health service, with more doctors per patient than any other high prevalence country (including the US). Indeed, the US (where an estimated 1.2 million were living with HIV in 2013) seemed intent on ridiculing Cuba’s approach to the virus.

Some of the criticisms were directed at claimed human rights aspects of Cuba’s achievements. It was often stated or implied that men who have sex with men were especially targeted by, for example, Cuba’s imposed ‘quarantine’. The quarantining started when little was known about the course of the illness, but it was relaxed once more was known. A number of personal accounts, some from men who have sex with men, now make it clear that many of the people quarantined are grateful to have received the care they got at the ‘sanitaria’ (there are links to other similar articles from this article).

An article by Tim Anderson finds that the quarantine did not target men who have sex with men; it also finds that other procedures were carried out in accordance with international guidelines. Anderson notes that Cuba was ‘more thorough’ in their testing and tracing procedures. Cuba has continued to make improvements in how they deal with the epidemic, which is a low level one, with men who have sex with men being the most affected group.

Sarah Z Hoffman refers to Cuba’s HIV program as ‘the most successful in the world’. Cuba approached HIV with the aim of reducing the likelihood of those infected going on to infect other people. That may sound like an obvious aim, but the greater thoroughness of Cuba identified by Anderson can be contrasted with a reduction in contact tracing in many countries, where it was claimed that certain groups were being unfairly targeted by such measures.

Cuba also started providing all HIV positive people with antiretrovirals in 2001, which they produced themselves as generic versions. Other countries had to wait a long time before they could provide more than a small fraction of HIV positive people with ARVs, and they had to pay astronomical amounts of money for them for years (although the costs are far lower now).

Hoffman writes “HIV infected people must provide the names of all sexual partners in the past six months, and those individuals must be tested for HIV. People found to have any sexually transmitted disease must undergo an HIV test as well. Voluntary HIV screening is encouraged.”

This is one of the places where practices in Cuba differ from practices in most other countries. This is called ‘contact tracing’ and it’s a vital tool of infection control. But in most countries people can claim anything they wish to about their sexual partners, that they have never had sex, that they have only engaged in heterosexual sex, that they have never injected drugs, etc. If people can withhold such information then contact tracing is impossible.

(My previous post is about a rare and valuable contribution to the history of HIV in Africa from John Potterat’s book ‘Seeking the Positives’, much of which concentrates on his work on HIV and STI epidemiology in the US. There’s a link to the chapter here. The approach the US adopted towards HIV could hardly have been more different from that of Cuba. Unfortunately, most other countries, certainly most poor countries, wedded themselves to the US, till death…etc.)

As a result of not tracing contacts, or of not doing so very assiduously, countries like the US, with extremely high transmission rates in certain groups, have never got their epidemic under control. In common with Cuba, the largest proportion of new HIV infections now is among men who have sex with men. Unlike Cuba, there is also a large injecting drug population in the US. But where contacts are not traced, they can not be offered the same opportunity to avoid infection if they are negative, or avoid infecting others if they are positive. Nor can they be ‘connected to care’ as quickly as possible.

In fact, many of the things western countries write copiously about, such as early testing and treatment, universal testing, elimination of mother to child transmission, universal access to treatment, were achieved in Cuba years ago, but have never been fully achieved even in some western countries. Where HIV prevalence is highest, in southern and eastern African countries, some of those achievements may not be realized in our lifetime.

Unfortunately for the worst affected countries, the rights of individuals are claimed to be foremost. Their contacts, past and future, are not treated as individuals. If the individual has multiple partners and chooses not to reveal that they engage in high risk practices, that’s considered to be the individual’s business. If the individual has had no sexual partners, or no HIV positive sexual partners, then the source of their infection needs to be identified. But in high prevalence African countries tracing of non-sexual contacts is rare. What you do find a lot of in research is findings referred to as ‘biased’, because the researcher expected every HIV transmission to be a case of sexual transmission.

(Despite the apparent desire of most countries to protect people’s individual rights in relation to HIV, this approach seemed to go out the window when the virus involved was ebola. Some ‘infection control’ measures seemed to involve groups breaking into people’s houses, forcing them into shabby health facilities, burning their property in public, spraying their houses, breaking up families and communities, etc. Who knows what approach will be taken to the next headline grabbing epidemic.)

So why all the attention and resources for a country that appears to have lost control of HIV a long time ago, and why all the rhetorical questions about Uganda, how their ‘success’ can be replicated, etc? More importantly, why so little attention for Cuba, and why is it so belated? We can learn a lot from both countries. Instead, we should be asking what Cuba did right, and continues to do right, but what Uganda did wrong, and continues to do wrong.

Cuba’s approach to HIV may have been the most successful anywhere. Some would go further and claim that Cuba may be the only country that was seriously threatened by the virus, but gained complete control over the epidemic early on, and retained that control. In the sphere of human rights, also, Cuba has made a lot of progress. Uganda, on the other hand, continues to move in the opposite direction in the fields of public health, human rights, HIV, political stability, economy, etc.

Long Standing De Facto Gag Rule on HIV in ‘Africa’


The gag rule about abortion is not the only gag rule, and even the ‘global gag rule’ never went away in developing countries. Organizations running sexuality, HIV, reproductive health and other programs have long had to cover up anything that might appear to show a pro choice attitude of any kind.

They knew that funding, especially from the US, would be threatened by even appearing to be pro choice in any way.

But there is a much more pervasive gag rule relating to HIV in high prevalence countries, all of which are in Africa. The history of HIV has some very shocking aspects that you won’t hear much about through reading some of the better known literature.

A chapter from John Potterat’s Seeking the Positives, entitled ‘Why Africa?: The Puzzle of Intense HIV Transmission in Heterosexuals‘ is available free of charge on ResearchGate.net. Potterat delves into a long list of the things that those researching into and writing about HIV are not allowed to speak of openly, even when they are reporting findings from scientific research.

For example, many researchers and other professionals believe in African ‘hypersexuality’ as an explanation of hyperendemic HIV (which is only found in African countries). This is just a prejudice, but it informs the bulk of HIV writings in scientific journals. Here’s a quote from Catherine Hankins, who was an epidemiologist at UNAIDS, that would make a Trumpite redneck proud.

Many assume that HIV really is a threat to all, regardless of sexuality, location, circumstances, etc, and don’t realize that there was a decision made to present the virus that way to appease those who felt they were being stigmatized as being most at risk; Potterat refers to the ‘consensus’ emanating from the WHO and CDC in 1988, and elsewhere to ‘consensus epidemiology’. Facts have never had as high a status as consensus where HIV in high prevalence countries is concerned.

People who have never been to a high HIV prevalence country could be forgiven for accepting that the risks of HIV transmission from unsafe healthcare and other skin-piercing practices are extremely low. But this is also claimed by people who live and work in high prevalence countries.

In fact, foreigners working for big institutions such as UN bodies, are issued with a specially written booklet warning them to avoid healthcare facilities that haven’t been approved by them. Yet people living in these countries, who must avail of unsafe facilities are not warned.

Potterat notes that he and his colleagues were told by a high ranking official ‘not to tell African people’ that their healthcare facilities are so dangerous that foreigners are warned not to use them.

In reality, Potterat’s recommendation that people in high HIV prevalence African countries be warned about the risks they face, and that conditions in health facilities be improved, is a very modest one. People have a right to such information, and to safe facilities; so why the reluctance to inform them?

People have a right to accurate, accessible, appropriate health information under international human rights law. Politically motivate agreements about what to tell the public and, more importantly, what to tell people in high HIV prevalence countries, do not constitute such health information.

Reluctance, apparently, partly stems from the fact that CDC, WHO, UNAIDS and the like think it will ‘water down’ their ‘messages’ about ‘safe’ sex. In other words they want to continue lying about ‘African’ sexuality, as well as about unsafe healthcare. They don’t want to be exposed as having spent three decades not addressing the main drivers of HIV, and instead lying about sexual behavior in high HIV prevalence countries. Hankins uses that argument in the BBC article linked above.

These revelations from Potterat’s book are all shocking because we are left with the question of how many people would be alive today if they had known what these international health institutions all knew so long ago. Such questions were asked about the inaccurate information spread by Mbeki’s regime in South Africa, so why not ask the same of international health institutions, universities, donor countries and others?

Tens of millions of people have been infected with HIV in high prevalence countries since the 80s; how many of them would be HIV negative now if they had known the risks of unsafe healthcare? Half of them? More than half? Perhaps we’ll never know. But the lies are well documented in Potterat’s writings and must be followed up by the scientific community.