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Category Archives: behavioral paradigm

Dear Researcher, What Kind of Whore am I?


My last blog post was about a researcher who seems to have found what she was looking for (young girls who claim to have had sex for money to buy sanitary towels) and now uses the finding to get publicity and, presumably, funding, or justification for funding if she has already received some.

Ten percent of the 15 year olds, allegedly, made this claim, which amounts to fewer than 20 people from a survey of 3000. But the researcher took what they said at face value because they were saying the right thing. The researcher is selling menstrual cups (specifically, mooncups) in a high HIV prevalence area.

Another piece of research looked at serodiscordance, where each partner in a couple has a different HIV status, one positive and one negative (or they are each infected with a recognizably distinct viral type). It was found that more women than men are in discordant relationships, which is taken to indicate that women are more ‘promiscuous’ than men, or more ‘promiscuous’ than previously assumed.

The researchers concluded that “due to social desirability bias, women in stable relationships practice concurrent partnerships more than reported”. In other words, the women whose partner was HIV negative but who were themselves HIV positive ‘lied’ about their sexual behavior.

The researchers, following the received view of HIV, believe that the virus is almost always transmitted through heterosexual sexual intercourse in high prevalence countries in ‘Africa’, but not in most countries outside of ‘Africa’. Therefore, HIV positive women in a discordant relationship must have been lying.

In the mooncup research, the researcher believed what was heard, and reported it as she heard it. But in the serodiscordance research the researcher did not believe what was heard, so it was classed as a ‘bias’, no different from saying that those women were lying.

Although there are all kinds of names for various different biases that plague certain kinds of research, it’s a bit harder to find names for the biases of researchers, who go into the field armed with their prejudices and the findings that they (and probably their funders and institutions, etc) seek, and proceed to grab what fits their preconceptions, discard what doesn’t, and put a spin on anything else that can be salvaged.

A very disturbing paper claims to identify three paradigms of ‘transactional sex’, for those who thought it only referred to sex for money. They identify:

Sex for basic needs
Sex for improved social status
Sex and material expressions of love

So there you have it! Since the study is not about people who are seen as straightforward sex workers and people who are married, it’s difficult to imagine what proportion of females could not be associated with any of these categories. Some authors on the subject conclude that females who don’t receive anything for sex (and, I guess, some who do), are coerced into having sex.

This is about sex in ‘African’ countries, by the way, so you don’t need to start thinking about any time you may have had sex that some zealous researcher could fit into one of their little boxes, unless you are ‘African’. Of course, if you are male (and ‘African’) then you are likely to be a John or a sexual abuser.

So how can you tell if you have had sex for reasons that the researcher can not classify as transactional or forced, how to tell if you are a prostitute, a victim, a John or a sexual abuser? Or, looking at it another way, if you are not from an ‘African’ country, neither are you married, nor a sex worker, have all your sexual experiences been of a kind that these researchers might approve?

Those writing on the subject often talk of females lacking power, and of the intervention they are researching, such as marketing mooncups and the like, as ’empowering’. Indeed, the subject of power often arises in discussions of HIV in ‘Africa’. As if we (the reseachers, NGOs, etc) have power and we are looking for downtrodden victims upon whom we may bestow it, if they just give the right answers to our questions (we can also tread down those awful men, too).

Shockingly, these well funded researchers really do wield great power in developing countries. They define what kind of person you are, a victim, an abuser, a prostitute, a john, and they tell others how to use these definitions, giving them a small share of their funding if they allocate people to the correct boxes.

The same researchers decide what they will accept as a valid response, on the one hand, and what they will put down to bias on the other, effectively calling the respondent a liar, unable or unwilling to accurately describe how they see themselves and their place in their own environment.

There are some who seem to go to the field with a blinkered view of HIV in high prevalence African countries, where they refuse to accept evidence that doesn’t fit their preconceived notions of ‘African’ sexuality, where sex is generally paid for (somehow) or forced, always ‘unsafe’, rarely (if ever) for pleasure and certainly not for love. If you are a HIV positive ‘African’, heck, even if you just have sex, you are (probably) a whore or a john.

Questionable Research: Are Menstrual Cups A Hard Sell?


In May of 2016, the English Guardian gushed:

“‘Girls are literally selling their bodies to get sanitary pads,’ says Dr Penelope Phillips-Howard. ‘When we did our study in Kenya, one in ten of the 15 year old girls told us that they had engaged in sex in order to get money to buy pads.'”

The 2015 study that they carried out is more careful in some ways. “Caution is suggested in interpreting the data provided, and particularly for analyses on low prevalence behaviors such as sex for money for sanitary products.” The study also reveals that the number of 15 year olds who claimed to have had sex to get money, specifically to get sanitary pads, was fewer than 20.

Another Guardian article appeared in the last few days on the same subject. The articles are both promoting a menstrual cup as an alternative to expensive, disposable sanitary pads, or similar ware.

Access to sanitary ware is vital for the health and welfare of girls and women, and making devices like the menstrual cup available is an excellent alternative to the ridiculously expensive disposable sanitary ware available in most places.

But if it’s a right, and vital for health, why dress this up as an attempt to ‘rescue’ 15 year olds who are said to be resorting to ‘transactional sex’ just to purchase sanitary pads? One of the researchers also claims the girls are often coerced into having sex.

Back in sensationalist mode, the recent Guardian article cites the same author and study:

The situation is so dire that in a 2015 study of 3000 Kenyan women, Dr Penelope Phillips-Howard found 1 in 10 15-year-old girls were having sex to get money to pay for sanitary ware.”

Note, 3000 women, but fewer than 200 15 year olds. Both Guardian articles are about having sex for money to buy pads, rather than having sex in return for pads. But the abstract of the 2015 article seems to blur this distinction, which I would argue is an important one if we are to judge whether this research is useful, however abused, or highly questionable.

There is also an article from a 2013 study, for which Phillips-Howard is a contributor, which clearly talks about both, having sex for money to buy sanitary ware and having sex for sanitary ware.

However, the 2013 article is quite different because it states that “Girls reported [my emphasis] ‘other girls’ but not themselves participated in transactional sex to buy pads, and received pads from boyfriends.” Claiming that other people do this may indicate that the respondent has simply heard such things, perhaps from peers, teachers, various sources of information about sanitary matters, or even presentations about HIV.

Going back to the two possible phenomena, sex to get pads (from sexual partners) and sex to get money to buy pads, do either of these stand up to scrutiny? The first seems unlikely on the basis of other claims and findings made in the literature cited, such as that few people want to talk about menstruation; males don’t at all, even many females generally don’t.

Do men buy sanitary pads as gifts for their sexual partners? I imagine this is rare. I have bought sanitary pads in East African shops and people don’t hide their reactions. Perhaps it happens.

Claims about girls engaging in ‘transactional’ sex can be found throughout the HIV, health, development and anthropological literature, all over the place. Sex in Africa is a common obsession among academics, journalists, policy makers, civil servants, Guardian readers, etc. There are claims that some girls have sex for status, food, mobile phones, phone credit, just about anything that a girl may want (or that they may be said to want).

Is it credible that lots of girls have ‘transactional’ sex for money, which they then use to buy sanitary pads? Well, again the articles state several reasons to think that they don’t, or don’t do so very much. After all, they have families with small incomes, they need to buy food, to pay bills, including school fees. Would they prioritize sanitary pads, having gone as far as to engage in ‘transactional’ sex?

The literature goes from claiming that girls say other girls have sex for sanitary pads or sex for money to buy sanitary pads, to claiming that 10% of 15 year old girls claim that they have had sex for money to buy sanitary pads.

By my reading, the causal link between engaging in ‘transactional’ sex and purchasing sanitary pads is lost if the girls don’t have sex in return for the pads. But if the claim is that they have sex for the pads then the literature itself undermines the claim that some men are happy to purchase them as gifts in return for sex.

We can’t rule out the possibility that someone has engaged in ‘transactional’ sex for money to buy sanitary pads, nor the possibility that someone has done so in return for sanitary pads. But Phillips-Howard’s claim that girls are literally selling their bodies to get sanitary pads looks more like a desperate attempt to shore up poor quality research than a genuine argument for the benefits of providing girls in developing countries with the most appropriate means to ensure menstrual hygiene.

Gag at the Stench of Bullshit: Durban HIV Conference


After decades of insisting that HIV in sub-Saharan African countries is almost always a result of ‘unsafe’ sex, and that infections can be averted by ‘abstaining’ from sex, being ‘faithful’ to one partner and using condoms, the massive HIV industry may now be admitting that these ‘behavioral’ approaches don’t work, and never have:

Dube believes that early access to ART (antiretroviral therapy) is the way forward after a decade of trying to change behaviour barely dented the transmission rate.

But the industry still insists that HIV is mostly transmitted via heterosexual (penile-vaginal) sex, in sub-Saharan African countries. Curiously outside of sub-Saharan Africa, the bulk of HIV transmissions are due to receptive anal sex and intravenous drug use.

The reasoning for this is not so complex: the vast majority of people engage in sexual intercourse at some time in their life. Just as the HIV industry really (really, REALLY) wanted behavioral programs to work, because few viable alternatives were acknowledged, now they really want antiretroviral drugs to work.

Instead of identifying people infected with HIV as early as possible, monitoring their health, and putting them on ARVs when they clearly need them, the HIV industry has come up with ‘treatment as prevention’, which means anyone testing positive for HIV will be put on ARVs, for the rest of their life.

Not content with getting as many HIV positive people on ARVs as possible, the industry has also come up with PrEP (pre-exposure prophylaxis). This means that people can go on ARVs before they are infected. The industry can then ‘target’ the people they say are in need of PrEP. After all, who wants to prevent infection with such a lucrative virus?

Hey presto! If almost everyone engages in sexual intercourse at some time, then almost everyone is at risk! The number of people infected with HIV globally is between 30 and 40 million (depending on whose figures you use), which might seem like a very large market for the bloodsucking HIV industry.

But in a few strategic moves, the market rockets to hundreds of millions, perhaps even a billion or so, as rubbish behavioral problems are dropped all over the developing world, to be replaced by the imposition of enormous drug programs. Sure, individuals don’t have to pay, but someone does; who, by the way, is going to pay?

Sex workers are an easy target, always have been. Even deciding who is a sex worker is a matter of debate among the HIV ‘experts’ (but certainly not among sex workers themselves). But how about the biggest HIV positive demographic in South Africa, which has the largest HIV positive population in the world? Teenage girls, many of whom are just becoming sexually active. What about giving PrEP to all of them, says the HIV industry?

Never mind prevention they say, treatment IS prevention they say, as they bank their billions and brand yet more sectors of the population as ‘at risk’. Meanwhile, young people are demanding things that they feel are important, such as sanitary pads and condoms (how much was spent on condoms over the last 20 years?)

Some people are even demanding cancer drugs. Why are some people not able to access these? Is it because cancer is old news? Not ‘sexy’ enough any more? Or is it because many of the patents on cancer drugs have long expired, and the number of people involved is only a fraction of the number of people who can have ARVs for life; cancer drug regimens are not life-long.

If HIV negative people are to be given ARVs to ‘protect them from infection’, what about people who are already HIV positive but still don’t have access to treatment? There are an estimated 20 million HIV positive people thought to be unable to access treatment (again, depending on who is counting, according to which methodology).

Poor Charlize Theron, who says it’s not an honor to host the Durban HIV conference because ‘we should have eliminated HIV by now’. So they didn’t tell her that this is the biggest opportunity in history that Big Pharma has had to put hundreds of millions of people on overpriced drugs that they will need for the rest of their lives?

Take a look at: Seeking the positives, by John Potterat


In an important contribution to the history of medical research, John Potterat’s new book, Seeking the Positives, recounts his involvement in research on sexually transmitted disease and HIV. Chapter 7 recounts researchers’ failure to explain how so many Africans get HIV (chapter 7 is available for download at http://home.earthlink.net/~jjpotterat/book.html).

The AIDS epidemic has been a disaster for tens of millions of Africans. What has not been widely recognized is the damage to medical research – epidemiologists have not done what is required to show how so many Africans get HIV. In a closed-door meeting at WHO in 2003, John described HIV epidemiological research in Africa as: “First World researchers doing second class science in Third World countries.”

How will the medical research community rebuild competence after its deliberate incompetence in not explaining and thereby containing Africa’s AIDS epidemic?

John’s book offers much more than a history of HIV research failures. He and his staff at the Colorado Springs public health department reduced STD in the community. Working with researchers from CDC and elsewhere, they tested new control strategies and documented what works – demonstrating the importance of contact tracing and network analyses to understand and limit STD transmission. Research in Colorado Springs has had an impact on STD prevention programs around the world.

But this is not only history – the human costs of research failures are continuing. According to the latest UNAIDS’ estimate, 1.4 million Africans got HIV in 2014 (see:http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdf). If someone could tell Africans how they are getting HIV, they might be able to protect themselves and collectively to wind down their epidemic.

I recommend the book for reading in epidemiology classes – to foster truthniks and doubters, so we will have the experts we need in future health crises. When you get the book, I recommend you start with a brief look at Appendix 3, which lists individual and STD/HIV program awards.

Charging HIV-positive husbands and wives with adultry — and lying about it


return to first research page

A wife, husband, and children can be hurt when a gossip — with no evidence — spreads rumors that the wife or husband have lovers.

This situation threatens many HIV-positive married men and women in Africa. HIV prevention programs say most infected adults — including wives and husbands with HIV-negative partners — got HIV from lovers, even if there is no evidence they had lovers, and even if they deny it. Such HIV prevention messages are equivalent to rumors — averring without evidence that people had secret lovers and lied about it.

Researchers have supported such unfounded “rumors.” For example, a UNAIDS-funded study in Zimbabwe followed adults to see who got HIV and what were their risks. After finding and reporting that “[t]hirteen of 67 individuals seroconverting in this study reported no sexual  partners in the inter-survey period..” the authors opined: …misreporting of sexual behaviour may explain some of these infections….”[1]

Wife with HIV, husband without

Many women are victimized by such unsupported suspicions. National surveys in 24 African countries during 2010-14 report the percentages of couples with HIV in one or both partners. In 14 of 24 countries, if a married woman was HIV-positive, more than 50% of husbands were HIV-negative (Table 1). This is not explained by women getting HIV before marriage – even among married women aged 30-39 years, an HIV-positive wife was more likely to have an HIV-negative than an HIV-positive husband in 12 of 24 countries (Table 1).

Table 1: Among married women who are HIV-positive, what % of  husbands are HIV-negative?

wife+ husband-

Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence).

Seeing such data and recognizing “women’s low self-reported levels of extramarital sex, a World Bank economist opines: “…I conclude that the sizable fraction of discordant female couples is extremely difficult to explain without extramarital sex among married women.”[2]

Most countries in Africa routinely test pregnant women for HIV. Hence, the wife is often the first partner to know her status. If the husband subsequently goes for a test, he is more likely to test HIV-negative than HIV-positive in most countries across Africa.

What is he to think? Should he believe his wife? Or should he believe healthcare professionals (behaving like gossips) who propose his wife lied? It is relevant, as well, that healthcare professionals have a conflict of interest – the alternative to blaming wives for adultery is to acknowledge their HIV may have come from unsafe healthcare.

Husband with HIV, wife without

Similarly, blaming all HIV on sex encourages wives to blame HIV-positive husbands for having lovers and lying about it. In 15 of 24 countries, when the husband is HIV-positive, at least 50% of wives are HIV-negative (see Table 2).

Table 2: Among married HIV-positive men, the % of wives HIV-negative

husband+ wife-
Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence).

References

1. Lopman, Garnett, Mason, Gregson. Individual level injection history: A lack of association with HIV incidence in rural Zimbabwe. PLoS 2008: Med 2(2): e37. Available at: http://www.plosmedicine.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pmed.0020037&representation=PDF

2. de Walque D. Sero-discordant couples in five African countries: implications for HIV prevention strategies. Pop Dev Review 2007; 33: 501-523. Abstract available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1728-4457.2007.00182.x (accessed 28 October 2018).

Cambodia


Roka Commune outbreak

In November 2014, a 74-year old man in Roka Commune, Cambodia, tested HIV-positive. He sent his granddaughter and son-in-law for tests. They also tested positive. Alarmed by these unexpected HIV infections, more residents of Roka Commune went for tests; many were HIV-positive.

The next month, December 2014, Cambodia’s Ministry of Health initiated an investigation with collaboration from WHO, the US CDC, UNAIDS, UNICEF, and the Pasteur Institute in Cambodia.[1]

Three papers report results from this investigation.[2,3,4] Results are limited to 242 persons testing HIV-positive through end-February  2015. Comparing HIV-positive residents with neighbors, infected residents had received more injections, infusions, and blood tests. Reports say nothing about specific failures in infection control (e.g., did providers give injections after changing needles but reusing syringes? did providers give infusions with reused plastic tubes and saline bags?). Many persons were co-infected with hepatitis C, which unsafe healthcare had been spreading in the community for years before the HIV outbreak.

Foreign organizations helping with the investigation sequenced several hundred HIV (determined the order of their constituent molecules) from the community. Almost all sequences were very similar, showing fast transmission from 1 to 198 infections in 15 months, September 2013 to December 2014 (see Figure 2b in [4]). These sequences can be presented as branches in a “tree” (see below, Figure 1; this tree uses most of the same sequences as reference 4, but suggests transmission took several years rather than 15 months). The upper right section of the tree shows the cluster of very similar sequences from Roka. (Most sequences in the lower part of the tree are “controls,” which means the HIV came from other times and places.) The tree shows each HIV infection as the right end-point of a short horizontal line. The left ends of these lines show estimated connections to earlier estimated infections. The timeline at the bottom of the figure shows time going from left to right, showing the estimated dates of transmission from earlier to later infections.

Figure 1: Cluster of 198 infections in Roka, Cambodia, linked by transmissions during 2011-14[5]

env_timetree_baltic (1)

Using information from these reports, one of the managers of this website (DG) estimated the transmission efficiency of HIV through contaminated injection equipment at 4.6%-9.2% (this is the risk that an injection administered to an HIV-positive person during the outbreak transmitted HIV to a subsequent patient).[6]

Other information related to the Roka outbreak

In early 2017, a newspaper article reported 292 infections in the outbreak.[7]

As in many other nosocomial HIV outbreaks, children were on the front lines: 22% of cases were in children <14 years old.[2]

Alerted by the investigation, people looked for unexpected infections and unsafe practices elsewhere in Cambodia. A December 2015 BBC article – one year after Roka broke into public view – reports continued and common unsafe practices.[8] In mid-February 2016, an NGO reported 14 patients testing HIV-positive – 10 from Peam village in Kandal Province, a village of 1,000, and 4 from neighboring villages[9]. The article reported 32 previously known infections in Peam village, for a total of 42 or 4.2% of 1,000 villagers. In interviews, persons newly identified with HIV denied sexual risks and suspected infection from injections by a specified local doctor.

See also these dontgetstuck.org blogs posts

References

1. Eng Sarath. Ministry of Health, Cambodia. 24 December 2014. HIV cases in Sangke district, Battambang. Available at: http://www.cdcmoh.gov.kh/97-hiv-cases-in-sangke-district-battambang

2. Mean Chhi Vun et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. Morbidity and Mortality Weekly Report 2016: 65:  142-145. Available at: http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm (accessed 28 March 2016).

3. Saphonn V, Fujita M, Samreth S, et al. Cluster of HIV infections associated with unsafe injection practices in a rural village in Cambodia. J Acquir Immune Defic Syndr 2017; 75: 285-e86. Available at: https://journals.lww.com/jaids/Citation/2017/07010/Cluster_of_HIV_Infections_Associated_With_Unsafe.19.aspx (accessed 12 February 2018).

4. Rouet F, Nouhin J, Zheng D-P, et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin Infect Dis 2018; 66: 1733-1741. Available at: https://pubmed.ncbi.nlm.nih.gov/29211835/ (accessed 24 February 2021).

5. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/ (accessed 15 November 2018). This figure has been copied by permission from Bedford Lab.

6. Gisselquist D. HIV transmission efficiency through contaminated injections in Roka, Cambodia. biorxiv 2017. Available at: https://www.biorxiv.org/content/biorxiv/early/2017/05/15/136135.full.pdf (accessed 12 February 2018).

7. Millar P. How the residents of Cambodia’s “HIV village” are coping more than two years on. Southeast Asia Globe, 15 March 2017. Available at: http://sea-globe.com/how-the-residents-of-cambodias-hiv-village-are-coping-more-than-two-years-on/ (accessed 14 August 2017.

8. John Murphy. BBC, 17 December 2015. A country in love with injections and drips.
Available at: http://www.bbc.com/news/magazine-35111566

9. Aun Pheap, George Wright. Doctor denies spreading HIV in latest outbreak. Cambodia Daily News 22 February 2016. Available at: https://www.cambodiadaily.com/news/doctor-denies-spreading-hiv-in-latest-outbreak-108791/ (accessed 28 March 2016).

See also:

Kehumile Mazibuko. News Tonight Africa, 4 December 2015. Cambodia: unlicensed medical practitioner sentenced for infecting more than 100 people with HIV. Available at: http://newstonight.co.za/content/cambodia-unlicensed-medical-practitioner-sentenced-infecting-more-100-people-hiv

Khy Sovuthy, Anthony Jensen. Cambodia Daily, 8 December 2015. In HIV case, key evidence trails behind guilty verdict. Available at: https://www.cambodiadaily.com/news/in-hiv-case-key-evidence-trails-behind-guilty-verdict-102320/

Why do UNICEF, WHO, and UNAIDS choose to stigmatize rather than protect African youth?


(return to first research page)

Beginning in early 2015, UNICEF with UNAIDS, WHO, and other organizations initiated the All In to #EndAdolescentAIDS program. The program has some good points – e.g, promoting more HIV testing and better treatment for HIV-positive adolescents.

However, the program is off the mark on prevention. It says nothing about risks adolescents in Africa face to get HIV from blood-contaminated instruments during health care (blood tests, dental care, injections, etc) and cosmetic services (tattooing, manicures, hair styling).

Ignoring such risks while focusing only on sex stigmatizes those who are already infected (aha! you had careless sex!) and misleads those who are HIV-negative to ignore blood-borne risks.

Evidence HIV-positive adolescents did NOT get HIV from sex

The best available evidence – from national surveys – suggests less than half of HIV infections in African adolescents came from sex. For example, in national surveys in Kenya, Lesotho, and Tanzania, majorities of HIV-positive youth aged 15-19 years reported being virgins (Table 1). Across these three countries, 57% (36 of 63) HIV-positive youth in the survey samples reported being virgins.[1]

table 1 adolescents

Some HIV-positive teens may have gotten HIV from their mothers when they were babies; but without antiretroviral treatment (ART), which arrived late in Africa, survival to adolescence would be unusual. Thus most adolescent virgins with HIV likely got it from blood contacts. If virgins are getting HIV that way, some non-virgins are likely getting it the same way.

Using data from national surveys in Lesotho, Swaziland, and Zimbabwe, and assuming no lying about sexual behavior, Deuchert estimates only 30% of HIV-positive never-married adolescent women aged 15-19 years got infected through sex.[2] What if some lied? Deuchart does the math: “The assumption that HIV is predominantly sexually transmitted is valid only if more than 55% of unmarried adolescent women who are sexually active have misreported sexual activity status.” (Tennekoon makes a similar analysis.[3])

But let’s cast the net wider: During 2003-15, 45 national surveys in Africa reported the %s of (self-reported) virgin and non-virgin youth aged 15-24 years with HIV (see Table 2 at the end of this blog post). Young men and women got HIV whether or not they virgins.

For example, in Congo (Brazzaville), Rwanda, Guinea (2012), Democratic Republic of the Congo, and Gambia, the %s of young women that were HIV-positive was greater among virgins than among all young women. Among young men, the % with HIV was the same or greater among virgins vs. all young men in Tanzania (2007-08), Congo (Brazzaville), Sierra Leone (2013), Guinea (2005), Mali, Sao Tome and Principe, Burundi, Benin, Burkina Faso, Niger, and Gambia.

Across all 45 surveys, the median ratio of the %s of self-reported virgin young men with HIV to all young men with HIV was 0.75 (last line, Table 2). Across all 45 surveys, the median ratio of the %s of self-reported virgin young women with HIV to all young women with HIV was 0.33 (last line, Table 2). And, as noted above, many infections in non-virgins likely came from blood-borne risks.

The only way to say most HIV infections in adolescents in Africa come from sex is to throw away the best evidence we have – to assume survey data are wrong because self-reported HIV-positive virgins are lying. That seems to be what experts at UNICEF, WHO, and UNAIDS have done – ignoring evidence to accuse HIV-positive adolescents of unwise sex, and accusing them also of lying if they say they are virgins.

Stigmatizing HIV-positive African youth for unwise sexual behavior is a form of abuse. Because young women are more likely than young men to be exposed to HIV during more frequent health care and cosmetic procedures, not warning about bloodborne risks contributes to unrecognized violence and abuse targeting African women.

table 2d adolescentstable 2e adolescents

References

1. Brewer DD, Potterat JJ, Muth SQ, Brody S. Converging evidence suggests nonsexual HIV transmission among adolescents in sub-Saharan Africa. J Adolescent Health 2007; 40: 290-293. Partial draft available at: https://www.deepdyve.com/lp/elsevier/converging-evidence-suggests-nonsexual-hiv-transmission-among-105k5VXKQE (accessed 19 December 2015).

2. Deuchert E. The Virgin HIV Puzzle: Can Misreporting Account for the High Proportion of HIV Cases in Self-reported Virgins? Journal of African Economics, October 2011, pp 60-89. Abstract available at: http://jae.oxfordjournals.org/content/20/1/60.abstract (accessed 19 December 2015).

3. Tennekoon VSBW. Topics in health economics. PhD dissertation. Washington State U, 2012. Available at: http://research.wsulibs.wsu.edu:8080/xmlui/bitstream/handle/2376/4270/Tennekoon_wsu_0251E_10484.pdf?sequence=1 (accessed 18 December 2015). See also an earlier paper by

 

 

 

 

 

HIV and the Real(ly Lucrative) Risks


In an article entitled the ‘real’ risks of sex with someone who has HIV, the authors concentrate on a handful of considerations, but don’t mention some of the most important risks. They seem intent on advertising (or advertorialing) HIV drugs, like a lot of these media articles. Also, the article is about a HIV positive American celebrity, so there may be no real intention of informing people about HIV.

Anyhow, the gender of the HIV positive person is not mentioned. In Western countries, very few males are infected through heterosexual sex. The majority are either infected through male to male sex or through injected drug use. Of course, many may claim to have been infected through heterosexual sex, and even believe they were. But the chances of a man being infected by a HIV positive woman through penile-vaginal sex are so low that there are few documented instances, where there is no possible doubt about the source of the infection.

The position is completely different for women. It is perfectly possible for a HIV positive man to infect a HIV negative woman through penile-vaginal sex, although the risk is not especially high. There are many other factors that can increase the risk, and they are too numerous to list, but the overall health of both parties may be an important one. This is not just about sexual health, but rather the state of each person’s immune system at the time.

Anal sex is also a significant risk for men and for women. But the risk for a man who never engages in receptive anal sex, only insertive anal sex, remains far lower, and this is the case for anal sex with men and with women. The receptive partner, whether male or female is at very high risk. A lot of people wouldn’t admit to engaging in anal sex of any kind, and they may not always remember what they did and didn’t do.

There are even highly complex reasons why someone may be more susceptible or more infectious at a given time, or under certain circumstances. Too little is known about these matters and they will probably remain little understood until someone finds out how to make money out of such knowledge. Concentrating on therapies is a lot easier, because they are already the source of incredible amounts of money, even by pharmaceutical industry standards.

If you don’t know the most significant risks of being infected with HIV, or of infecting others, you can’t protect yourself from them. So this Yahoo! article is very dangerous. But it is merely a function of the relationship between Big Pharma and big media. In the end, such sources of dis/information are not the best way of protecting yourself or others from HIV and other diseases. Broaden your research base, open your eyes, and think.

Zimbabwe: Thought Embargo at HIV Inc to Continue Indefinitely


The Zimbabwean health minister, David Parirenyatwa, has exposed his complete ignorance about the country’s HIV epidemic by claiming that there is ‘rampant homosexuality’ in prisons, and that this is making an especially large contribution to high rates of HIV transmission in these institutions.

Naturally, there are some men who have sex with men in prisons, and not just in Zimbabwe. But that is not just because men are more likely to have sex with men when incarcerated for lengthy periods with men, denied conjugal visits and other rights. It’s also because having sex with someone of the same gender can itself attract a prison sentence.

However, what the health minister fails to realize is that there tend to be very poor health services in prisons. If he had inspected health services in prisons he would have come to a very different conclusion. Indeed, had he inspected health services outside of prisons he would also have come to a different conclusion about Zimbabwe’s massive HIV epidemic.

Prevalence in Zimbabwe had already reached about 15% in the early 1990s (compared to about 1% in South Africa). But it shot up to almost 30% before the end of the decade, then dropped back to early 1990s levels in less than 10 years. The figure has remained at roughly half its peak for the last decade or so.

The death rates required to bring prevalence from 30% to 15% in less than 10 years must have been phenomenal. Did the esteemed (and I’m sure astute) Parirenyatwa notice a sudden rise in prison populations during the 1990s, followed by a profound drop, with a subsequent flatlining thereafter? Or a sudden rise in male to male sex? Or a sudden rise in ‘unsafe’ sex among heterosexuals?

I don’t think so. But I also doubt if the health minister has a clue what was going on in the country’s health services then, or perhaps now. Massive increases in HIV transmission during the 1990s was very likely a result of a decrease in levels of safety in health facilities, along with a probable increase in usage of health facilities.

Minister, HIV is most efficiently transmitted through unsafe skin piercing procedures, such as injections with reused injecting equipment, surgical instruments, etc, also through unsafe body piercing and tattooing, and even through unsafe traditional practices, such as scarification, blood oaths and others.

Just how unsafe would cosmetic and traditional practices be in a prison? We can only guess. How safe would they be elsewhere? It’s unlikely anyone has checked. If they have, they would have found it difficult to publish the findings.

It’s easy to blame high HIV prevalence on ‘promiscuity’, male to male sex, carelessness, stupidity, malice and other phenomena, so beloved by journalists and others milking the HIV cow, far too easy. But ministers, journalists, academics, and even those who have reached lofty heights in international NGOs and the like, are still permitted to consider the roles of unsafe healthcare, cosmetic and traditional practices. I invite them to do so.

‘African’ Sexuality: Consensus or Prejudice?


An article by Damien de Walque, entitled ‘Is male promiscuity the main route of HIV/AIDS transmission in Africa?‘, seems curiously behind the times. He refers to the “pervasive if unstated belief in the HIV/AIDS community…that males are primarily responsible for spreading the infection among married and cohabiting couples”.

Disturbingly, de Walque goes on to conclude that, because women are as likely as men to be the infected partner in discordant relationships (where only one partner is HIV positive), both male and female promiscuity must be the main route of transmission. This is by no means the only possible conclusion; far more women than men are infected with HIV in high prevalence African countries, but this could be a result of other risks, particularly non-sexual risks.

However, women being almost as likely as men to be the infected partner in discordant relationships was not a new discovery when de Walque was writing in 2011. Gisselquist, Potterat, Brody and Vachon published an article in 2003 entitled ‘Let it be sexual: how health care transmission of AIDS in Africa was ignored‘, which presents evidence from the 1980s showing that women are almost as likely as men to be the positive partner in discordant relationships. They also show that neither is promiscuity the main route.

The article by Gisselquist et al looks back at papers from the 1980s demonstrating clearly that the bulk of HIV transmission in African countries is not sexually transmitted. Data collected about sexual behavior does not support the view that Africa is exceptional. Rather, data about other risks, such as unsafe healthcare, cosmetic and traditional practices was either not collected, or was ignored.

Even the abstract gives a good sense of what was going on in the 1980s (and is still going on). I’ll cite it in full, adding italics for emphasis:

“The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in African adults emerged no later than 1988.We examine evidence available through 1988, including risk measures associating HIV with sexual behaviour, health care, and socioeconomic variables, HIV in children, and risks for HIV in prostitutes and STD patients. Evidence permits the interpretation that health care exposures caused more HIV than sexual transmission. In general population studies, crude risk measures associate more than half of HIV infections in adults with health care exposures. Early studies did not resolve questions about direction of causation (between injections and HIV) and confound (between injections and STD). Preconceptions about African sexuality and a desire to maintain public trust in health care may have encouraged discounting of evidence. We urge renewed, evidence-based, investigations into the proportion of African HIV from non-sexual exposures.”

Consensus among influential experts should be based on available data; not only did these experts ignore a lot of available data, they failed to collect a lot of data that could have led to a very different consensus. But several long-held preconceptions, for example, about ‘African’ sexual behavior, may have had undue influence on the consensus of these experts. It is these preconceptions that I am interested in.

By claiming that UNAIDS is going to change its name to UNAZI (as far as I know, they are not going to), I wished to draw attention to the fact that the still current claim that HIV is almost always transmitted via heterosexual contact in African countries (but nowhere else) is based on the preconceived views of some very prejudiced ‘experts’. UNAIDS acquired a consensus of experts who had decided, before the institution was established, that they were going to concentrate almost exclusively on heterosexual transmission, and diminish the role of unsafe healthcare and other non-sexual transmission routes.

The big lie about HIV in ‘Africa’ is that 80% (sometimes 90%) of prevalence is from ‘unsafe’ heterosexual sex, and most of the remaining 20% (or 10%) is from mother to child transmission. This lie emerged in the 1980s, from ‘experts’ who knew that it was a lie. The entire HIV industry is still based on this lie three decades later. As a result, most African people are unaware that unsafe healthcare, cosmetic and traditional practices may be a far bigger HIV risk than sexual behavior.