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Keep HIV Prevalence Low in Burundi with Safe, Accessible Healthcare

A recent newspaper article on Burundi refers to the country’s failure to achieve a Millennium Development Goal (MDG) to get “HIV prevalence to zero by 2015”. This is not an MDG and is a confusion with one of UNAIDS’ slogans, which goes ‘zero new infections, zero AIDS-related deaths and zero discrimination’.

The journalist continues “One of the reasons for this [failure] is an unequal access to quality healthcare and prevention services for high-risk groups in Burundi.” One of the consequences of UNAIDS’ insistance that HIV is almost always transmitted through ‘unsafe’ sexual behavior in African countries (but not in non-African countries) is that no one in high prevalence countries wants to be associated with efforts to reduce transmission amongst those who seem to be most likely to be infected and to infect others.

Sex education in schools is almost non-existant, or it’s provided by religious groups whose aim can be to misinform rather than enlighten; sex work is illegal in many African countries; male to male sex is illegal and carries risks that go beyond HIV; harm reduction programs to reduce transmission among intravenous drug users by supplying them with safe injection equipment and other facilities is a political hot potato, with many donors actively discouraging it because it ‘encourages drug use’, etc.

But quality healthcare is denied to the majority of Burundians, not just those who fall into one of UNAIDS’ numerous ‘most at risk’ groups. Indeed, those who have had the best access to healthcare may also be more likely to be HIV positive – urban dwelling, wealthy people with higher levels of education.

Burundi is a very poor country, with the lowest expenditure on health in East Africa, but also the lowest HIV prevalence. At 1.4%, prevalence is only a fraction of that of Swaziland, where the majority of poor, rural dwelling, poorly educated women give birth with the assistance of a skilled healthcare worker. Only around 30% of Burundians from similar backgrounds do so.

The article gives the impression that poverty in some way causes HIV and sex work, because poor people have no option but to have sex for money or food or other benefits, as if poverty were something quite neutral in the absence of HIV and sex work. But poverty may also increase HIV transmission by exposing people to unsafe healthcare, or to the absence of healthcare.

If unsafe healthcare is the only option, people may risk infection with very serious illnesses in health facilities. Yet avoiding them altogether means they risk many other serious illnesses. Those engaging in sex work face terrible occupational risk, but if healthcare facilities are also unsafe, their non-sexual risk for HIV and other diseases may also be increased.

No one working in development would argue that poverty is unimportant, but it doesn’t play exactly the role in HIV transmission claimed by UNAIDS and the HIV industry in general. Poverty denies people access to healthcare altogether, or it condemns them to risking unsafe healthcare. So poverty reduction and greater access to healthcare needs to mean safe healthcare, otherwise access to healthcare and poverty reduction may be dangerously counterproductive.

Intergenerational Sex and Marriage: Just Another HIV Myth?

In 2007 the Population Council published an article on early marriage and HIV in Kenya. There’s nothing surprising about a eugenicist or ‘population’ NGO taking a close interest in such matters, of course, and the Population Reference Bureau published an article about cross-generational sex in various Africa countries in the same year. Both articles express concern about these phenomena potentially posing a risk for HIV transmission.

What is surprising is the figures used by the Population Council, listed below. The province where early marriage is most common, Northeastern, is the province where HIV prevalence is lowest, by a long shot. Early marriage is also less common in Nairobi, where HIV prevalence is second highest in the country. Where HIV prevalence is highest, Nyanza, early marriage is not particularly common. At least, there is no noticeable correlation between the phenomenon and HIV prevalence.

% married by 18 years HIV prev 08-09*
Northeastern 56 0.9
Eastern 16 3.5
Coast 34 4.2
Central 15 4.6
Rift Valley 35 4.7
Western 32 6.6
Nairobi 12 7
Nyanza 34 13.9

The relevant table is 14.5, page 217

In fact, these NGOs should have been very suspicious. HIV prevalence often tends to be higher among wealthier, better educated, urban dwelling, employed people, whereas intergenerational sex and marriage may be more closely associated with poorer, less well educated, rural dwelling, unemployed people.

So it is significant that AidsMap reported a presentation at the 21st Conference on Retroviruses and Opportunistic Infections (CROI). This presentation suggests that “Sex with older men is not placing women under 30 at higher risk of HIV infection in rural South Africa, and relationships with older men may even be protecting women over 30 from infection“.

The author of the study suggests that programs addressing relationships between older men and younger women may even stigmatize men and women in such relationships. But stigmatizing people with, or thought to be at risk of, HIV is something NGOs and international health institutions have never shied away from.

The media will be disappointed because they have enjoyed years of talking about sugar daddies and sugar mummies, which fits into the ‘all men are bastards, all women are victims’ paradigm of HIV transmission, and their concomitant assumptions that African men will do anything for sex and African women will do anything for money.

Many population (and eugenicist) NGOs generally also claim an interest in ‘reproductive health’, but their agenda often seems to veer towards matters that have little to do with health, and activities that have little to do with human rights. But for those that really are interested in health, there is another set of figures they may be interested in.

HIV prev 08-09 Medical supplies for common delivery complications
Northeastern 0.9 52
Eastern 3.5 61
Coast 4.2 59
Central 4.6 77
Rift Valley 4.7 49
Western 6.6 38
Nairobi 7 81
Nyanza 13.9 25

The Service Provision Assessment for Kenya for 2010 (Table 6.7, page 136) finds that only 25% of health facilities in Nyanza Province have essential supplies for common complications relating to child delivery, which means 75% of facilities lack “Needle and syringes, intravenous solution with infusion set, injectable oxytocic, and suture material and needle holder all located in delivery room area; oral antibiotic (cotrimoxazole or amoxicillin) located in pharmacy or delivery room area”.

With the highest HIV prevalence in Kenya, the fact that 46% of hospitals in Nyanza do not have all essential supplies for delivery, which refers to “Scissors or blade, cord clamp, suction apparatus, antibiotic eye ointment for newborn, skin disinfectant”, the Population Council and Population Reference Bureau may like to take a look at unsafe healthcare, now that intergenerational sex and marriage seem so much less of a priority now.

Again, these NGOs should also have noticed something important about HIV prevalence often being more closely associated with wealthier, better educated, employed, urban dwelling people: access to health facilities is also generally far higher among these groups. When poorer people with less education, those without formal employment and those who live in isolated rural areas do have access to health facilities, those facilities may turn out to be pretty unsafe. But that’s a matter for research that these NGOs haven’t yet carried out (or perhaps they just haven’t published it).

Ever-eager to snatch defeat from the jaws of victory, those who subscribe to the (eugenicist) population control theory of development in Africa, whether covertly or overtly, continue to receive generous funding. They don’t wish to lose any ground when it comes to pandering to the prejudices of those who still believe that Africans have loads of unsafe sex, and that this is why HIV prevalence is so much higher there. Yet, funding for unsafe healthcare always seems to put donors off their morning read, which is evidently when they set their funding priorities.

HIV Strategy: Blaming the Victim and their Individual Behavior

Since the early days of HIV/AIDS, finger pointing has been the main publicity angle. In Western countries the collective finger was pointed at men who have sex with men. Their reaction was to object to the finger being pointed at them and to insist that everyone is equally at risk. Though some still believe that everyone is equally at risk, it is not true. In Western countries the majority of HIV transmissions have always been among men who have sex with men, with a smaller proportion of transmissions through intravenous drug use.

But things are quite different in developing countries, particularly high HIV prevalence African countries. In high HIV prevalence countries men who have sex with men, intravenous drug users and even sex workers contribute a relatively small proportion of HIV transmissions. In fact, the largest contribution still appears to come from those with little or no risk; mainly monogamous heterosexuals. So the process of finger pointing often turns into one of victim blaming. After all, you can’t point the finger at everyone around you, nor at someone who is HIV negative; so the clearest ‘evidence’ of unsafe sexual behavior becomes HIV positive status.

This gives rise to the task of explaining how a virus that is difficult to transmit through heterosexual sex outside of Africa is so frequently transmitted through that route in Africa. The HIV industry needed to show that ‘Africans’ must be promiscuous, ignorant and unhygienic. This wasn’t too difficult because population control advocates (the word ‘eugenics’ is no longer fashionable), a significant proportion of wealthy NGOs operating in Africa, had had been playing the over-sexed, under-educated slum-dweller cards for decades.

The processes of pointing the finger at a particular group whose behavior was disapproved of, blaming those infected with HIV for their status, and concluding that HIV is all a matter of individual behavior, threw off course any efforts to reduce HIV transmission in developing countries. Although ‘prevention’ activities only receive a small proportion of HIV funding, that is still a massive amount of money. But prevention activities have rarely gone beyond exhortations to ‘behave’ in a particular way. The finger-wagging programs perfected by population control NGOs decades before HIV was identified became, and often remain, the state of the art of HIV prevention.

There has been plenty of research showing that these finger-wagging programs are of little or no benefit (except to the NGOs). An example of such research shows that “peer education programs in developing countries are moderately effective at improving behavioral outcomes, but show no significant impact on biological outcomes“. There is a voluminous body of literature showing that you can’t simply wag your finger at people and expect them to change their behavior, whether the aim is to address substance abuse, dangerous driving, over-eating or anything else.

Sometimes the association of HIV transmission with individual behavior is further connected with conditions that are beyond the control of the victim, for example, poverty. But this has also given rise to confusion: there is plenty of evidence that HIV in African countries is transmitted among wealthier people. This challenges the idea that HIV epidemics are driven by sexual behavior because, even if wealthy people ‘can afford to have a lot of sex and a lot of partners’, as the HIV industry would have it, there would need to be some poor people involved in this theory. Rich people don’t pay other rich people for sex.

Instead of looking beyond sex, or sex and poverty, it seems some researchers are convinced they will eventually find out how sex and economic inequalities ‘drive’ HIV epidemics. One paper concludes that “Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in [sub-Saharan Africa]“. But they don’t seem to consider the possibility that their protohypothesis about sex is simply wrong. They don’t seem to think that non-sexual transmission may be a very significant factor in the spread of HIV among wealthier people.

HIV can be transmitted through unsafe healthcare and other skin-piercing processes, such as various cosmetic processes. Wealthy people tend to have better access to healthcare. In fact, urban dwellers also tend to have better access to healthcare. Perhaps this is why the above paper found that HIV is “generally concentrated among wealthier men and women“. This may also explain why HIV “was concentrated among the poor in urban areas but among wealthier adults in rural areas” in a number of countries.

Instead of trying so hard (and failing, over and over again) to find out what it is about the sexual behavior of wealthy people and urban dwellers, perhaps researchers should look at non-sexual risks, as well as sexual risks. Could the risks that people face be determined by their wealth and environment, precisely because they are not sexual risks, but healthcare and other risks? These risks are clearly not *individual* risks. They relate to health-seeking behavior, but it is not the behavior of wealthy and/or urban-dwelling people that gives rise to infection with HIV in a hospital or salon; the risk of infection depends on whether the facility is safe or not (which might vary considerably over time).

Some historians of HIV, such as Jacques Pepin (The Origins of Aids), admit that HIV was mainly transmitted through unsafe healthcare for many decades, and hardly ever through sexual behavior. But they don’t explain how healthcare transmission magically disappeared in the 1980s even though conditions in many African countries remain very unsafe (although how unsafe they are is still a dangerously under-researched field).

Coupled with the magical disappearance of the risk of HIV transmission in under-equipped, under-staffed and badly run health facilities is the magical re-appearance of the promiscuous, ignorant and dirty African, though for many, this had never really gone away. Pepin vaguely mentions things like ‘urbanization’ as the main explanation for levels of promiscuity for which there has never been any evidence and which do not explain very high rates of heterosexual transmission of HIV anyway.

Ugandans have recently responded to having the finger pointed at them by allowing an ‘anti-homosexuality’ bill to be passed, effectively saying ‘it’s not us, it’s them’. Various human rights groups, and even some donors, may belatedly object to such disgusting measures, which are being copied by other African countries. But the objection needs to be directed at the approach to HIV that began a long time ago, and began in Western countries, not in African countries. Men who have sex with men are by no means the only group who have been blamed for HIV epidemics. Other groups include long distance drivers, sex workers, house girls, fishermen, miners, and many others. It’s this finger-pointing approach that gives rise to the stigma that those pointing the finger claim to abhor.

Thirty years into the HIV epidemic (I’m adopting the view that HIV is not a pandemic because most people don’t face any risk of being infected and prevalence is, and will remain, low in most countries) research institutions, NGOs, international bodies and, perhaps most importantly, donors are still obsessing about sexual behavior and pretending that HIV status is up to the individual when it is clear that a large, but as yet unestimated, proportion of infections is a result of unsafe healthcare and other skin-piercing processes.

UNAIDS’ Dubious Claims about HIV/AIDS 2013

UNAIDS risk missing their target of reducing “sexual transmission of HIV by 50% by 2015“. But there is a way of meeting that target, and they could meet it by tomorrow. If they belatedly admit that HIV is far more easily transmitted through unsafe healthcare, they could begin to estimate the contribution of things like reuse of needles, syringes and other equipment that comes into contact with blood and other bodily fluids.

This would also greatly assist their progress towards their ‘ZeroDiscrimination’ target too, because even though they can’t reverse the damage they have done by insisting that Africans are irremediably promiscuous, the status of this claim as institutionalized racism will eventually become clear, at least to those who are prepared to think the issue through a little (a surprisingly small number of people so far).

After all, reducing ‘sexual transmission’ is one of their stated goals, whereas UNAIDS has barely breathed a word about transmission through unsafe healthcare in their 20 year, multibillion dollar, celebrity studded reign. They could just quietly (imperceptibly, even) reveal some changes in the way figures are collected and next December 1, a re-estimation of non-sexual transmission of HIV could be the subject most deserving of their customary (spontaneous) standing ovation module.

UNAIDS are uncharacteristically frank about mass male circumcision, which is something of an embarrassing fiasco: “As of December 2012, 3.2 million African men had been circumcised […]. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011. Still, it is clear that reaching the estimated target number of 20 million in 2015 will require a dramatic acceleration.” (They don’t say how many of the 3.2 million circumcised over quite a few years would have been circumcised anyway but took advantage of the free (anesthetized) operation.) Might this spell an unobtrusive retreat from this dangerous imperialist program?

But one of the heftiest pieces of bullshit in the ‘report’ (and there is stiff competition) is about “the goal of providing antiretroviral therapy to 15 million people by 2015”. They say that “As of December 2012, an estimated 9.7 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.6 million over 2011. That brings the world nearly two-thirds of the way towards the 2015 target of 15 million people accessing antiretroviral treatment.”

The difference between UNAIDS’ claim and the truth is expressed in a few words, such as ‘were receiving’ therapy. If they said that 9.7 million people had been recruited on to a therapy program, that might have been true (or somewhat closer to the truth). But 9.7 million is, at best, the number of people who have at one time been put on a program. Neither UNAIDS, WHO, PEPFAR, CDC nor anyone else knows how many of those 9.7 million ever took the drugs, or for how long, how many dropped out of the program, how many were recruited on to two or more programs or simply died, etc.

No one knows, and no one really cares because 9.7 million is an impressive figure, and it sounds like a good attempt at the 15 million target. There is not much incentive to estimate how many people are alive and on antiretroviral treatment, indeed, such an estimate could prove fatal to several substantial institutions (not just UNAIDS, which seems to thrive on failure to achieve anything at all, aside from spending money and institutionalizing bigotry). Is the true figure 8 million people, 7 million, or some far lower number? Billions of dollars say that no one is going to ask this impertinent question (unless they are not in receipt of any of those billions, and never will be).

Unsafe healthcare does exist in extremely poor, high HIV prevalence countries, surprising as that may seem to those who are used to the mainstream view that HIV is hardly ever transmitted through heterosexual sex in every country in the world, but almost always transmitted through heterosexual sex in a handful of African countries. What contribution does unsafe healthcare make to the worst HIV epidemics in the world, all in sub-Saharan Africa? Would it be the one or two percent UNAIDS grudgingly suggests, or something far higher? We don’t know yet. No billions have been offered for the answer to this question.

Using cumulative figures is great, because you get that great ‘step’ effect when you produce bar graphs, and there is nothing like comforting, progressive steps to convince people that everything is good in UNAIDSland, and in the HIV industry in general. A very achievable 2015 target would be the abolition of UNAIDS and the promotion of safe healthcare. Because unsafe healthcare risks the spread of HIV, something UNAIDS has never got around to accepting. But I suspect that instead, there will be a continuation of the finger-pointing and victim-blaming that has characterized the mainstream approach to HIV in high prevalence countries so far.

More MDG Scapegoats: Industrial Disputes and Gay People

Another Millennium Development Goal (MDG) scapegoat. It sounds like bloody cheek to suggest that Kenya’s failure to reduce new HIV infections as quickly as predicted is a result of health personnel strikes. True, there have been strikes, but the country’s health services were decimated years ago by the strictures of international financial institutions and sheer neglect, and allowed to rot. Successive governments have also done an appalling job when it comes to industrial relations.

According to the article, Prevention of Mother to Child Transmission (PMTCT) coverage “fell by 20 percent in 2011-2012”, from 66% to 53%, representing 13,000 children newly infected with HIV. The 2015 target is close to 100% but, at 38%, Kenya seems unlikely to reach it, and the same could be said for most other African countries. However, there is nothing to back up the ridiculous claim that strikes played a significant part in such a massive fall in coverage.

The article does state that “Experts agree on the main reason behind the reduction in PMTCP – disruptions in the health services”, but that’s hardly a smoking gun. There have been numerous antiretroviral drug stockouts and other disruptions, for various reasons, and these may have a lot more to do with such a large drop in coverage.

Another possible problem in meeting the MDGs could be a transition process that PEPFAR funded programs have been going through. In South Africa it is estimated that “between 50,000 and 200,000 people may have fallen out of care in the transition”. Indeed, there are probably several reports available that would point to the reason for the fall in coverage, but journalists and politicians don’t seem to like reading reports.

Yes another article from Kenya has come up with an even more impertinent suggestion. It claims that there has been an ‘upsurge’ in gay sex, which is slowing the ‘war’ on HIV. The article suggests that Kenya has achieved a lot, with prevalence dropping from 7.2% to 5.6%. Perhaps they are expecting the next set of results to be less flattering.

Men who have sex with men face very high risk of being infected with HIV, and of transmitting it. But Kenya and most other African countries have refused to accept that this is a group that needs special attention, preferring to accept the HIV industry’s contention that most HIV transmission in African countries is a result of unsafe heterosexual sex. It sounds far more manly, doesn’t it.

Because transmission has decreased in some populations, the contribution of infections from men who have sex with men may look like it is increasing. But the claim that the country may not meet some of its MDGs because of an ‘upsurge in gay sex’ is as outrageous as the claim that industrial disputes are disrupting progress in reducing new HIV transmissions.

These are cheap shots at health personnel, gays and traditional birth attendants. But governments, NGOs, UNAIDS, donors and the lucrative HIV industry need all the help they can get when it comes to explaining why billions of dollars did not seem to result in particularly rapid declines in HIV transmission. There will be more to come.

Predicting the Millennium Development Goal Scapegoats

Come 2015 a lot of people will still be flailing about looking for scapegoats to explain their country’s falling short of various Millennium Development Goals. But one group of scapegoats must be well accustomed to having the finger pointed at them; traditional birth attendants (TBA). In an article from Uganda appearing on, TBAs are being “blamed for HIV among newborn babies”.

Is the finger of blame being pointed at them on the basis of research this time, or is it the usual politico/journalistic reflex? The sheer vagueness of the article suggests that it is based on the latter. What self-respecting politician or journalist would read research, anyhow? No checkable source is cited, though that’s nothing unusual for; and one of the people cited says “there are many deaths and new HIV infections among new babies that go undocumented and […] the statistics may be falling short of the exact number”.

If some of the new infections among babies are documented, why are they not also investigated? Are the mothers HIV positive? Or are some of the mothers HIV negative? HIV negative mothers with HIV positive babies are not uncommon, but investigations into this phenomenon in African countries is very rare indeed.

An obvious question for politicians, journalists and others who wish to indulge in the perennial practice of blaming people, whether they be TBAs, men who have sex with men, women, foreigners, truckers or whoever else, is why HIV prevalence tends to be a lot higher in areas where people have better access to health facilities. TBAs tend to be more common in isolated and rural areas, where HIV prevalence is generally a lot lower.

The suggestion is that TBAs are not able to protect babies of HIV positive mothers from being infected, whereas qualified health personnel may be able to prvent mother to child transmission. True as this may be, how are TBAs supposed to be able to resolve this problem themselves? If it is the case that about half of all deliveries are overseen by TBAs, rather than conventional health personnel, this is hardly the fault of TBAs. They are not drawing big salaries, nor are they receiving thorough training or any other incentives for their work.

There are severe shortages of skilled health personnel in Ugandan health facilities. The facilities are stretched beyond their limits already. Is the government going to import enough doctors, nurses and others to fill the 50-60% shortfall that many facilities are experiencing? And more importantly, if the health facilities are going to be even more oversubscribed than they currently are, how safe will they be then? They are not currently safe places to give birth and some health figures show that those attending health facilities could be at higher risk of being infected with HIV.

Before blaming TBAs, it would be a good idea to carry out some research to find out exactly how so many babies are being infected with HIV, and how many have HIV negative mothers. Once that is clear, Uganda will be in a position to figure out what to do next, though it remains to be seen whether the country will be provided with the means to do anything effective. Donors are often keen on providing various health services for high profile, newsworthy conditions, but they are a lot less enthusiastic when it comes to ensuring that health services are safe.

Justine Sacco: Dangerous Truths and Dangerous Falsehoods about HIV

An American on her way to South Africa is said to have Tweeted “Going to Africa. Hope I don’t get AIDS. Just kidding. I’m white!” This is a heartless and insensitive remark to make. But what makes it most heartless and insensitive for a white American to say it is the fact that it is so true. In the US, African Americans accounted for 44% of all new HIV infections in 2010, despite representing only 12-14% of the population. Also in the US, men who have sex with men are said to represent about 4% of the population, but account for 63% of all new HIV infections in 2010, and a disproportionate number of them are black/African American.

Even in South Africa HIV prevalence among white people is very low. But national prevalence is amongst the highest in the world and there are more HIV positive people in South Africa than in any other country. While America has the worst HIV epidemic in the developed world, with over 1.1 million HIV positive people, the majority of infections arise among men who have sex with men and (to a lesser extent) intravenous drug users. HIV infection among white heterosexuals who have no serious risks, such as receptive anal sex or intravenous drug use, is very low.

The American who tweeted the first stupid, but sadly true, remark offended so many people that she arrived in South Africa to find that a storm had erupted on Twitter and she had lost her job. So, to make matters worse, she made a statement to a South African newspaper which contained a dangerous but often heard falsehood:

“For being insensitive to this crisis — which does not discriminate by race, gender or sexual orientation, but which terrifies us all uniformly — and to the millions of people living with the virus, I am ashamed.”

This is completely untrue, as the figures for the US show so clearly. About two thirds of people living with HIV globally are black Africans. An estimated 60% of HIV positive people in Africa are female, compared to only 20% of new infections in the US in 2010. Hispanics and Latinos in the US made up 21% of new infections in 2010; the rate of infection was 2.9 times higher in Latinos than it was in white males; it was also 4.2 times higher in Latinas than in white women.

HIV most definitely does discriminate by race, gender and sexual orientation. This is not a new discovery, either. It may be an acceptable thing to say in certain circles, but we should never forget the differences between HIV in Africa, where the majority of HIV positive people live, and HIV in developed countries, where HIV is less prevalent overall, and is rare among heterosexuals who have no serious risk behaviors.

Justine Sacco, who tweeted the remark, is so right to think that she is very unlikely to be infected with HIV; a lot less likely than a black African, and also less likely than a black or Latino/Latina American. It is disturbing to think that so many people continue to believe or say otherwise. Why is HIV prevalence so high among black Africans and black/African Americans, yet comparatively low among white people, especially white men who engage in no serious risk behaviors?

Happy New Year to All our Visitors

In our first two full years online the Don’t Get Stuck With HIV website and blog has received 48,000 page views, over 31,000 of them in 2013. The number of monthly views has increased to a high of 3,600 in December 2013 and the daily average has reached 116 views in the same month.

With over 7,000 views, our Blood-borne Risks page (‘Estimated risks to transmit HIV through various skin-piercing events’) was the most popular, followed by the home page, at 6,000 views. Sexual transmission risks, our pages about dental care, tattooing, hairstyling (etc), bloodtests and injections all received over 1,000 views each.

Also, a couple of blog posts were very popular, especially ‘Have we ignored a very simple procedure that could significantly reduce the risk of sexual transmission of HIV to men from women?‘ (nearly 2,000 views) and ‘Denied, withheld, and uncollected evidence and unethical research cloud what really happened during three key trials of circumcision to protect men‘ (1,600 views). A post on genital hygiene also received almost 1,000 views.

An analysis of about 4,000 search queries, comprising about 500 search terms, revealed that searches about syringes, other medical instruments and their uses accounted for about one quarter of all queries. Tattoos, dental care, manicures and pedicures and HIV transmission risk accounted for another 1,300 queries. About 260 searches were about circumcision if you add in searches for ‘Prepex‘, which is a fairly popular subject.

We have had visitors from 177 different countries, although we only 10 or fewer page views from 64 of those countries. With nearly 20,000 views from the US since February 2012, no other country comes close, although nearly 5,000 have been from the UK. India, Canada and Australia have accounted for another 7,000 views.The highest number of views from an African country was 864, from South Africa.

Our top referrer, accounting for over 30,000 views, was Google, mostly; about 3,000 were from Facebook, Reddit, Twitter and a few other tools account for a few hundred views each, although stimulating referrals from Facebook and Twitter required a disproportionate amount of work.

We thank visitors for viewing our site and blogs. We hope you found what you were looking for. We welcome comments and feedback and are grateful for what we have received so far. Using the above data, we intend expanding and reorganizing Don’t Get Stuck With HIV over the next year and hope we keep expanding.

All the best for 2014!

Guardians of the Orthodoxy: Writing about Rights and Rites

[Cross posted from the Blogtivist site]

Following a facile article in favor of mass male circumcision on the site (which I discuss on another blog), where the author went to some lengths to pretend he was not in favor of it, there is an article defending circumcision as a religious rite for Jewish people, with even a single mention of Muslims (at a time when even vaguely pro-Muslim, or non-anti-Muslim, sentiment in the media is particularly unfashionable) in the English Guardian. The title of the Guardian article reads: “A ban on male circumcision would be antisemitic. How could it not be?” The article purports to be a response to the Council of Europe’s ‘comparisons’ of male genital mutilation with female genital mutilation, with the author claiming there is no acronym for the former, suggesting that she has familiarized herself with neither the literature nor the operation.

But enthusiasm for circumcision is not confined to the operation as a religious rite. The big money is behind it as a ‘preventive’ against HIV and several sexually transmitted infections. Starting with adults and teenagers as targets for mass male circumcision campaigns, proponents have long been setting their sights on infants. Never mind the fact that most infants don’t engage in any kind of sexual behavior, least of all a kind that would be claimed to increase the risk of HIV transmission in those who have not been circumcised, not even by the most rabid proponent of the operation. Proponents of circumcision *want* to circumcise everyone, at all costs. What could be easier than starting with Africans, about whom few in the media care very much.

What has the argument got to do with the Guardian article? After all, is promoting circumcision for its claimed protection against HIV and the Guardian is promoting it as a religious rite. Well, both articles argue for the mainstream, financially sound view, the view that doesn’t fly in the face of current political sentiment and, more importantly, doesn’t fly in the face of important funders and supporters. depends on big pharma for its funding, along with some other wealthy institutions. The Guardian does not (entirely), but the Guardian’s Development section is funded by the Gates Foundation. That is higly significant when it comes to circumcision: the Gates Foundation is not just pro-circumcision, it funds one of the three main websites that promote circumcision, the Clearinghouse on Male Circumcision for HIV Prevention (the other two are the WHO and USAID).

In fact, the Foundation has also funded research carried out on African participants, research that is highly questionable, ethically as well as empirically. The Guardian’s article doesn’t appear on their Development section, but the connection with as huge a figure in the realm of circumcision promotion as Bill Gates is of a significance that should not be dismissed lightly. In addition, the Guardian article defends circumcision as a religious rite, but the article, by implication, opposes non-circumcision as a cultural right. Ethically and empirically dubious arguments are being shoved down the throats of Africans who do not currently circumcise, by people who do not consider for one moment that others have the right to choose not to circumcise, for cultural reasons. In Kenya, for example, it is for cultural reasons that members of the Luo tribe do not circumcise, and the same goes for many other Africans. It is not because they, like the Europeans, do not believe that the reasons given for mass male circumcision are completely unconvincing (arguments that have changed many times over the decades, except in the fervor with which they are expressed).

Back to Tanya Gold’s arguments in the Guardian. The Council of Europe, astutely enough, used the phrase violation of the physical integrity of the body’ to describe male circumcision. Even defenders of the operation could hardly deny that it violates the physical integrity of the body, could they? After all, that’s the point of it, as a rite and as a putative protection against HIV. Gold doesn’t tell us if she would object if the Council had attempted to suggest that parents be allowed to wait until their boys were old enough to decide whether to be circumcised or not. After all, compromises have been made before. Religious and cultural rites have been modified, even abandoned altogether. Tattooing and body piercing are not banned, but people are not permitted to tattoo and pierce parts of their babies, or even their children. These also violate the physical integrity of the body, although many people believe that they are worth having, for cosmetic or other reasons.

Even Gold is ‘repulsed’ by certain conditions that may surround circumcision, as if these conditions are not common. But most circumcisions are carried out in non-sterile, non-clinical conditions. In fact, like the violation of the physical integrity of the body, this is what makes them a matter of religious or cultural rite, rather than an operation that people can have carried out in a hospital, preferably when they are old enough to decide if they want to have their foreskin removed. Gold is not arguing for these conditions, but she is arguing for the religious right to perform circumcisions, and (perhaps) for the cultural right (or maybe she only considers Jewish circumcision to be worth defending? She is not clear on this.) Would Gold consider allowing parents to wait until their son could decide for himself? We expect those who perform rites and rituals we (in the West) consider repulsive, harmful, etc, to compromise or even abandon those rites and rituals. Why not discuss such a compromise with those who practice circumcision?

Gold objects to calling ritual circumcision a ‘violation of children’s rights’. But if there are exceptions to a law against violation of children’s rights, and violation of the physical integrity of the body in particular, how does this affect other children’s rights, even human rights in general? Can you argue that certain rights should be denied to those infants where parents believe that that would constitute a denial of their own religious rights to circumcise their child? Are human rights not interrelated, interdependent and indivisible: Gold seems to believe that circumcision does not involve violation of the physical integrity of the body, which is ridiculous, though she may prefer a different way of expressing the same thing. But she also seems to believe that circumcising infants is not a violation of their rights, and that banning infant circumcision denies parents their rights. She doesn’t make the distinction between infant circumcision and adult circumcision, but she seems to believe that the Jewish rite necessarily requires that it be carried out on infants.

Sadly, Gold has confined her arguments to the rights of Jewish people and chosen to write about antisemitism, rather than dealing with the broader issues of circumcision, human rights, the right to choose (particularly the right to choose not to circumcise), children’s rights and the like. True, she stuck her neck out by using the word ‘Muslim’ once and had the temerity not to include any other words beloved by journalists and home office officials as an accompaniment to the word ‘Muslim’, but she is clearly not in the business of standing up for what she believes in. It’s almost as if it’s not her job to believe in things. She invokes the typical ‘slippery slope’ argument: if circumcision is a “human rights violation against children… This is a trend – and so of course the next stage is prohibition.” We wouldn’t want to use emotive arguments, would we? There is a “dark marriage between human-rights agitators and racists”, according to Gold.

Which means that in objecting to infant circumcision, either as a religious rite or as a means of ‘preventing’ HIV, I am not just an antisemite, but I am also in bed with racists. I am supporting the “removal of Jews from Europe”. There was me thinking that I was arguing for human rights and against abuses of human rights, especially ones that journalists typically ignore, such as the rights of people who are not wealthy, or powerful, or perhaps people who are not even Guardian readers (who?), although I read the Guardian myself. Gold ends her piece with a sentiment that I would agree with if it were about journalists: “some Jews are always packed in their minds”. But I can’t reassert my credentials as a defender of human rights by accusing a journalist of having views that are formed independently of thought, evidence, logic or humanity; that’s shooting fish in a barrel.

What Happens when an ‘Activist’ Site is Bought off by the Multinationals?

The website ‘’, which is about HIV, but from a US point of view, has a recent article on circumcision by Ben Ryan, who is apparently a journalist. The strapline reads “Major studies support circumcision as prevention in Africa but a small yet vocal group argues the science is flawed. Can circumcision lower U.S. HIV rates?” The question is odd, because the article is not primarily about whether the operation can or can not lower transmission in the US (Ryan seems to suggest the answer is ‘yes’, but in a country where HIV transmission is predominantly among men who have sex with men and intravenous drug users, ‘no’ seems much more likely to be correct). The article is not really about the science either, but rather how that ‘science’ is used. (Even the title, ‘Cut to Fit’, sounds like an ironic reference to the author’s journalistic style.)

Ryan gives a selective review of the ‘science’ as he sees it, listing the major players in circumcision promotion, major in terms of the funding they receive, anyway. But all this is contrasted to an ‘ideological war’, by what Ryan brands as a small group of ‘dissidents’. The fact that many of those who oppose the imposition of mass male circumcision on tens of millions of African men who are not already circumcised, and male infants born to people who would not normally choose circumcision in infancy, are also scientists doesn’t seem relevant. The facts that skepticism is not inherently unscientific and that not all those who oppose mass male circumcision can correctly be referred to as ‘dissidents’ also seem unimportant to Ryan.

Although Ryan enjoys the term ‘intactivist’ to refer to people who oppose mass male circumcision on the grounds that the ‘science’ is highly flawed, this is not a widely used term by opponents. Some, like myself, oppose mass male circumcision on human rights grounds, and on the grounds that insisting on every man conforming to what is an American preference is an outrageous instance of cultural imperialism; but I certainly wouldn’t call myself an intactivist. According to Ryan, those who oppose mass male circumcision are mainly Americans and Europeans, without pointing out that those who promote it are almost all American, and all their funding is from America.

Part of the pretence of ‘giving both sides of the story’ involves interviews with people whom Ryan subtly belittles. One of those interviewed is John Potterat, who has carefully outlined the reasons for skepticism about the ‘scientific’ literature, which is freely available on the Social Science Research Network. According to Ryan and his favored informants, ‘dissidents’ are ‘hampering progress’, ‘spreading misinformation’ and ‘creating skeptics among those who stand to benefit’, the last referring to African people, whose future is being put in jeopardy because of a handful of unscientific people who are not epidemiologists or health scientists, and therefore should not hold an opinion on human rights or cultural imperialism, or so Ryan wants us to believe.

Ryan also interviews Rachel Baggaley, MD, who reassures us that the three million figure the WHO claims have been circumcised under the program sounds very low beside the 20 million originally hoped to ‘benefit’ from the operation because 20 million was an ‘aspirational’ figure; that the WHO had “underestimated the complexities and social sensitivities required to successfully promote the program in certain populations”. Could some of these ‘social sensitivities’ be similar to the views of the people Ryan considers to be a mere fringe of ‘dissent’? What Baggaley is delicately referring to is a dearth of safe health facilities, experienced health personnel and supplies needed to provide mass male circumcision that doesn’t result in a lot of botched operations and a huge increase in hospital transmitted HIV; also, that infuriating barrier to US cultural imperialism: foreigners, non-Americans.

Another ‘dissident’ cited is David Gisselquist, who has spent years publishing articles showing that unsafe healthcare and cosmetic practices may be making a significant contribution to the most serious HIV epidemics in the world, which are all in sub-Saharan Africa. The evidence for various types of non-sexually transmitted HIV is spread over hundreds of papers, written by people from various backgrounds, including public health, medicine, epidemiology and others. Indeed, one of the most important factors in transmitting HIV in African countries is circumcision itself, not just medical circumcisions carried out in unsafe health facilities, but also circumcisions that are carried out for cultural reasons, generally carried out in unhygienic conditions.

While presenting arguments against mass male circumcision in a context that makes them sound futile, Ryan lists the arguments for the program as if they were some kind of holy grail of truth, true for all time, in all places, as true for non-Americans as for Americans. Those pushing for the program keep going on about how similar the results of all the randomized controlled trials were, without this being held up to any kind of questioning; were these crusaders really so lucky, that all three trials came up with almost the same results? Why were the trials carried out in those areas, among those people, with those specific (poorly described) methodologies? Were any other trials carried out that may show the opposite effect? And why are the mass male circumcision programs going ahead in areas where HIV prevalence is already higher among circumcised men than uncircumcised men? What about current programs that are currently suggesting that mass male circumcision programs seem to be increasing HIV transmission, for example in Botswana and Kenya?

Oddly enough, Ryan gives the last word to Baggaley, who now refers to those who oppose the US funded mass circumcision of African men as ‘denialists’. She says they are generally not from high HIV prevalence countries, as if those promoting the program are. Seeing herself as having the perspective of a ‘young man in South Africa’, she finds objections to the operation to be ‘paternalistic’. Evidently she doesn’t see the paternalism in spending billions of US dollars on persuading people to be circumcised by telling them that there are numerous advantages to be enjoyed. How is that different from the various (also US funded) efforts to persuade poor people to be sterilized? How is that different from various syphilis ‘experiments’ carried out on African Americans, or similar ones carried out in Guatemala?

In stark contrast to Ryan’s stance of appearing to be ‘giving both sides of the argument’ while achieving no such thing, Brian D Earp has written a very cogent rebuttal of all the bits and bobs that Ryan thinks of as science. Earp does put his cards on the table: he is not undecided about whether mass male circumcision is a good or bad thing. But neither is Ryan, he just pretends to be. If you are interested in reading solid rebuttals of the arguments of those claiming to be ‘scientists’, and others, it’s worth reading Earp’s article in full. I can not do it any justice by paraphrasing it.

To conclude, branding people as ‘denialists’ or as being ‘unscientific’, even when the point is not a scientific one, or not entirely a matter of science, has a long history. Journalists pretending to be (or thinking that they are?) even handed is also an old trick. So people have to think for themselves: would you do it to someone you love, or would you wait till they were old enough to decide for themselves? And even if your answer is ‘yes’, and you would circumcise your son when he’s still an infant, does that mean tens of millions of African men should be persuaded by the US (and by US funded ‘Kofi Annan’ type figures) to do the same, using a hotch-potch of scare stories, half baked theories and outright lies, all dressed up as some kind of scientific canon, and that tens of millions of African infants should also be circumcised, their parents having been primed using the same body of ‘evidence’?