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Respecting women’s human rights by telling them about all their HIV risks


(A posting for International Women’s Day, 8 March)

For many years, WHO, USAID, UNAIDS, and other international and foreign aid organizations have misinformed women in Africa about risks for HIV. Experts inside and outside these organization have challenged bureaucrats to tell women what they need to know to protect themselves. But to no avail.

WHO, USAID, and other official organizations have blocked three messages that could help HIV-negative women to avoid HIV and help HIV-positive women to retain family trust: (a) Depo-Provera injections for birth control may boost women’s risk for HIV; (b) skin-piercing procedures in health care may infect women with HIV; and (a) an HIV infection is not a reliable sign of sexual behavior.

(a) Risks with Depo-Provera injections

Beginning in the early 1990s, studies that followed and re-tested HIV-negative women to see who got HIV found that women taking Depo-Provera got HIV faster than other women (Depo-Provera, injected every 3 months, mimics the hormone progesterone). As early as 1996, the South African Medical Journal reported high level debates about whether to promote Depo-Provera in Africa.

Evidence of risk to women had no apparent impact on donors’ efforts to inject hormones into African women. From 1996 to 2009, the number of women given hormone injections (primarily Depo-Provera) increased across Africa, especially in countries with the worst HIV epidemics. For example, among partnered women aged 15-49 years, the percentage using injected hormones increased from 5.5% to 17% in Swaziland, from 12% to 19% in Lesotho, from 20% to 28% in South Africa, and from 7.7% to 22% in Namibia. These rates are extraordinary on a world scale – outside Africa, only 3.1% of partnered women used injected hormones for birth control in 2009.

HIV is not the only health threat linked to Depo-Provera. In 2004, the United States (US) Food and Drug Administration forced Pfizer, the company that makes Depo-Provera, to add a “black box” warning to packages of Depo-Provera sold in the US: “Women who use Depo-Provera Contraceptive Injection may lose significant bone mineral density… Depo-Provera Contraceptive Injection should be used as a long-term birth control method (eg, longer than 2 years) only if other birth control methods are inadequate…”

Despite evidence linking Depo-Provera to HIV (and other health risks), WHO designates Depo-Provera as safe for general use (except for women with specific serious health problems, such as heart disease or breast cancer). WHO’s claim that Depo-Provera is safe came under renewed criticism in July 2011, when a study among discordant couples (one partner infected with HIV, the other not infected) in Africa reported that women using injected hormones were more than two times as likely to get HIV compared to women not using hormones for birth control.

WHO didn’t budge. Seven months later, in early 2012, WHO declared the new evidence – along with all previous evidence – to be inconclusive. WHO reissued its advice that “women…at high risk of HIV can safely continue to use hormonal contraceptives.” WHO’s only nod to the evidence was to say “women using progestogen-only injectable contraception [primarily Depo-Provera] should be strongly advised to also always use condoms…”

Why would WHO not warn women? Paula Donovan, co-director of AIDS-Free World and a long-time former UNICEF and UN official, explains that UN officials “were afraid that African women might abandon hormonal contraceptives altogether” leading to “more pregnancies…more maternal deaths…unsafe abortions” and more infected babies. Citing and quoting several UN documents about women’s rights, Donovan charges that “WHO and UNAIDS have violated [women’s] human rights by withholding the information. They have failed to inform women that using hormonal contraceptives may carry some risk… Women have the right to make fully informed sexual and reproductive health decisions, whether or not the UN likes those decisions.”

In a later publication, Donovan reminds those who wish to promote specific birth control methods that “No global experts or family planning organizations have the right to censor the life-and-death information women need in order to weigh their own risks… Women need information: complete, uncensored, and factually correct.”

(b) Risks to get HIV from skin-piercing health care procedures

Just as international and foreign aid organizations don’t warn women in Africa about evidence that Depo-Provera increases their risk to get HIV, these organizations also don’t warn them about risks to get HIV from reused and unsterilized instruments during skin-piercing health care procedures.

From the time AIDS was first recognized in Africa in 1982, there has been a lot of evidence that women have gotten HIV during health care. National surveys find that many clinics and hospitals do not sterilize instruments. Studies link HIV to injections, operations, blood tests, and other skin-piercing procedures. And studies and surveys report unexpected infections – for example, among women aged 15-49 years in Congo (Brazzaville) in 2009, more women who claimed to be virgins were HIV positive (4.2%) than all women (4.1%).

It’s clear from what WHO and UNAIDS tell UN employees that pretty much everyone throughout the UN system knows that health care available to the African public sometimes transmits HIV. In a 2004 booklet for UN employees, WHO and UNAIDS warn (p. 9): “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections.” But, “[b]ecause we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.”

Outside an approved clinic or hospital, WHO advises UN employees to (p. 23): “Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized.”

These organizations do not extend similar warnings and advice to African women. Just as not warning women about risks with Depo-Provera violates their human rights, similarly not warning women about risks to get HIV from unsterile instruments in health care violates their human rights.

(c) An HIV infection is not a reliable sign of sexual (mis)behavior 

Surveys and studies routinely find HIV-positive women who report no sexual exposure to HIV – some say they are virgins, others have an HIV-negative spouse and report no other sexual partners. The almost universal response to these findings by study teams has been that women lied – no matter what they said, they got HIV from sex.

By routinely disbelieving women, researchers protect and preserve the theory that almost all HIV in African women comes from sex. This theory – which grew out of racial stereotypes of sexual behavior and survives despite evidence – guides HIV prevention messages to misinform Africans that almost all HIV infections in adults come from sex.

What happens next completes a circle of distrust: These messages encourage men who are HIV-negative to think their HIV-positive wives got HIV from sex, no matter what their wives say (and similarly, encourage wives to think HIV-positive husbands were unfaithful). This is not a trivial matter. Most African couples living with HIV are discordant – only one is infected. Among discordant couples, the wife is equally likely to be HIV-positive as the husband.

Telling men and women in discordant couples that HIV surely comes from sex is like the town trouble-maker telling people their husband or wife is running around when there’s no evidence that’s so. An HIV infection is not enough evidence to show a wife was unfaithful. Many African women get HIV from health care. HIV prevention messages that focus only on sex add insult to injury, encouraging husbands, families, and friends to blame them for sexual misbehavior.

Conclusion: Getting good information to women is a do-it-yourself challenge

If international and foreign aid organizations waste – misuse – their money to misinform women about risks, that’s too bad. But let’s not let a bunch of irresponsible bureaucrats get in the way. Women’s lives are at stake. We can get these three messages to women through churches, NGOs, community groups, unions, and just talking to friends. Even bureaucrats who keep their jobs by telling approved official half-truths during working hours can pass these messages privately to friends and other contacts. Abraham Lincoln, the US president who ended slavery, said: “You may deceive all the people part of the time, and part of the people all the time, but not all the people all the time.” So despite the well-funded official half-truths from too many places, let’s take heart, and do what we can to get life-saving messages to women.

Denied, withheld, and uncollected evidence and unethical research cloud what really happened during three key trials of circumcision to protect men


[go to or return to first circumcision page]

Mass circumcision based on assumption, not evidence

Programs to circumcise millions of men in Africa’s are based on selected evidence from three trials in South Africa, Kenya, and Uganda.[1-4] Many people think these trials showed circumcision reduced men’s risk to get HIV from sex by more than 50%.

The trials don’t say that; specifically, the trials don’t say men’s infections came from sex. None of the studies collected all information needed to measure the impact of circumcision on men’s risk to get HIV from sex — asking about all blood and sexual risks and trading and testing sexual partners.[5]

Trials in South Africa and Uganda report new infections in men according to whether the men reported any possible sexual exposure to HIV (any sex without a condom). The evidence from these two trials suggests less than a third of men’s infections came from sex (see details below). It is, of course, possible that men misreported their sexual behavior. In other words, programs to circumcise men in Africa are not based on evidence, but rather on assuming away evidence.

Were men’s sexual partners HIV-positive? We don’t know. The Ugandan trial tested most of the men’s spouses and live-in partners for HIV (including women who did not want to know their HIV status [see “eligibility criteria” in reference 6]). The trial observed most new infections in men who reported no non-marital partner. But the trial has not reported the HIV status of the long-term partner of any circumcised or intact man who got HIV during the trial.

The South African trial found most new infections in men who reported only 0-1 sexual partner after the last HIV-negative test. The Kenyan study collected but has not reported information on men’s sexual behavior during the trial; at baseline a majority reported 0-1 partners in the previous 6 months. There is no indication either trial made any effort to trace and test the sexual partners of men who got HIV during the trial. This would have been not only good research, but was also ethical — protecting women who were not the source of men’s new infections.

Evidence from these trials supports other recommendations

Beware skin-piercing risks: As noted above (and detailed below), evidence from two trials says less than a third of men’s infections came from sex. Moreover, two studies report new infections in men with specific healthcare encounters. In the South African trial: men who “attended a clinic for a health problem related to the genitals” vs. men who did not were 5.7 times more likely to get HIV; and men who reported an injection, transfusion, and/or hospitalization vs. men with none of these risks were 1.7 times more likely to get HIV.  The Kenyan trial found four men new infections one month after they were circumcised. (See details below.)

Trust your body’s natural defenses: In Uganda, not washing one’s penis after sex cut men’s risk (whether circumcised or intact) for HIV. Thus, one message from the Ugandan trial is that natural defenses against HIV in sexual fluids may be as effective as circumcision (see details below and two other pages).

Beware unethical research: The circumcision trial in Uganda (together with research in a linked trial) tested many of the men’s wives and stable partners for HIV, but did not insist that women learn their HIV status or warn their husbands if women were HIV-positive. The trial followed men to see them get HIV, without warning them. The trial in South Africa followed men, at least some of whom did not know their HIV status. None of the trials required testing and warning wives and other partners when men got new HIV infections (see details below).

More details from the three trials

South Africa: The first study of the three studies to report was carried out in South Africa during 2002-05.[2] The study team solicited men willing to be circumcised, then on a random basis assigned half the men to an intervention group to be circumcised first and the other half to a control group to remain intact until the end of the study. The study team then followed and retested the men – circumcised and intact – at scheduled visits over as long as two years.

During follow-up, 20 men in the intervention (circumcision) group got HIV at the rate of 0.85% per year, while 49 men in the control (intact) group got HIV at the rate of 2.11% per year. If all the men’s infections came from sex, this says that circumcision cuts men’s risk to get HIV from sexual partners from 2.11% to 0.85% per year.

But did all or even most infections come from sex? Not according to evidence the study collected and reported. Twenty-three of the 69 men with new infections said they had no sexual partner or always used condoms from their last HIV-negative test to their first HIV-positive test. Men reporting no sexual risks got HIV at the rate of 1.11% per year. If these men are telling the truth, they apparently got HIV from blood during injections, dental care, tattooing, and other skin-piercing events. If men with no sexual risks got HIV from blood, we can estimate that men with sexual risks also got HIV from blood contact at the same rate. The rate of getting new HIV infections in men who reported at least one unprotected (without a condom) sex event was 1.86% per year. The modestly faster rate to get HIV in men reporting vs not reporting sexual risks explains less than 1/3 of the men’s infections (using standard epidemiological terms, the crude population attributable fraction of incident HIV associated with reporting any vs. no unprotected sex is 27%).

The study reported two health care exposure in men with and without new HIV infections: (a) men who “attended a clinic for a health problem related to the genitals” were 6.8 times more likely to get HIV than men without this risk;[2] and (b) men who reported injections and/or transfusion and/or hospitalization were 1.7 times more likely to get HIV than men who reported none of those events (see Authors’ reply in this link).[7]

The study team has not said what procedures men got at clinics treating genital health problems; it has also not reported HIV incidence separately for injections, transfusions, or hospitalizations. The study has not reported other healthcare procedures, such as infusions and dental care. The study has also not reported any data on skin-piercing cosmetic procedures; did they ask?

The study team could have done a better job identifying the sources of men’s infections if they had asked more questions and reported more data. But where is the failure? Did they not ask, or are they not telling? Like most studies on HIV in Africa, this study does  not give other researchers’ free access to collected data (with safeguards to protect participants’ confidentiality). Also, like most studies on HIV risk in Africa, this study has not disclosed its questionnaire and data collection forms – so there is no public record of what information they collected and chose not to report (chose to withhold).

Table: What information on sex and blood risks did the three studies collect and report for men with and without new HIV infections?

Risks for HIV South Africa, 2002-05 Kenya, 2002-06 Uganda, 2003-06
Blood-borne risks
Circumcisions No report of infections after circumcision 4 infections in the month after circumcision No report of infections after circumcision
Injections Collected but not reported Unknown Unknown
Transfusion Collected but not reported Unknown Unknown
Hospitalization Collected but not reported Unknown Unknown
Injections, transfusions and/or hospitalization Increases risk by 1.7 times Unknown Unknown
Visiting a clinic for a genital health problem Increases risk by 6.8 times Unknown Unknown
Other blood risks Unknown Unknown Unknown
Sexual risks
Any vs. no partners Collected but not reported Collected but not reported Increases risk by 2.4 times
<100% condom use Collected but not reported Collected but not reported Increases risk by 1.1 times
Any vs no partners or <100% condom use Increases risk by 1.7 times Collected but not reported Increases risk by 1.6 times
Any vs no non-spouse partner Collected but not reported Collected but not reported Collected but not reported
HIV status of spouse Not collected Not collected Collected but not reported
HIV status of non-spouse partners Not collected Not collected Not collected
Intact men waiting >10 minutes to wash penis sex Not collected Not collected Decreases risk by 87%
Circumcision Decreases risk by 60% Decreases risk by 53% Decreases risk by  55%

Sources: see references in the text.

Kenya: The Kenya study,[3] 2002-06, was similar in design to the South Africa study. The study circumcised some men, then followed and retested circumcised and intact men for as long as two years to see who got HIV. Nineteen men in the intervention (circumcised) group got HIV at the rate of 1.9% over two years, while 46 men in the control (intact) group got HIV at the rate of 4.1% over two years.

How many of the 65 men got HIV from sex? The study asked men about sexual partners and condom use, but reports this information for only seven men infected during the first three months of follow-up. Five of the seven reported no sexual partners from the time they entered the trial (using sensitive tests, the study could not find HIV in blood collected then) until their first HIV-positive test after 1-3 months. The study team has said nothing about tracing and testing men’s sexual partners – did they do it and not report it, or just not do it?

As for blood-borne risks, the study reports four men circumcised in the trial had new HIV infections one month later. Contaminated local anaesthetic or instruments could have infected the men during circumcision, but the study team says nothing about what might have gone wrong. Aside from circumcisions, the study says nothing about blood-borne risks. This is a glaring oversight, because the study team had in hand evidence linking HIV in the community to blood-borne risks: While recruiting men for the trial, men who reported one or more injections in the previous six months were 2.5 time more likely to be HIV-positive vs other men; men with tattoos were 2.2 times more likely to be infected; men who had ever received saro (traditional blood-letting) were 2.1 times more likely to be infected,[8] and men who reported “blood exchange” were 18.6 times more likely to be HIV-positive.[9]

Uganda: The study in Uganda, 2003-06, followed the same design as studies in South Africa and Kenya: assigning men randomly to be circumcised or to remain intact, then following them for as long as long as two years to see who got HIV. Twenty-two men in the intervention (circumcised) group got HIV at the rate of 0.66% per year, and 45 men in the control (intact) group got HIV at the rate of 1.33% per year.[4]

During follow-up, researchers asked men whether and how they cleaned their penis after sex, expecting that washing or wiping might be protective. Intact men who cleaned their genitals after sex, but waited at least 10 minutes to do so, got HIV at the rate of 0.39% per year. Also, men who wiped only without using water got less HIV than men who used water. The authors proposed that acid in vaginal fluids “may impair HIV survival,” so that washing these away with water may “facilitate viral survival and possible infectivity.”[10]

How did the men get HIV? Six men with new HIV infections reported having no sex partners during the period between their last HIV-negative and first HIV-positive test; 10 others with new infections reported always using condoms. Taken together, the 16 men who reported no possible sexual exposure to HIV got HIV at the rate of 0.72% per year, presumably from skin-piercing events that exposed them to HIV in blood. Men who reported any unprotected sex got HIV at the rate of 1.17% per year. As in South Africa, the marginally faster rate at which men who reported sexual risks got HIV explains less than a third of the new infections observed during the trial (using standard epidemiological analyses and terms, the crude population attributable fraction of incident HIV associated with having any vs no unprotected sex is 29%).

Unlike the other two studies, the Uganda study team traced and tested most of the men’s wives (and other long-term partners) for HIV.[6] However, the study has not reported the wives’ HIV status for men who got HIV. Did they get HIV from their wives? The study team is sitting on that information.

The Uganda study team provides no data on injections and other skin-piercing events for men with and without new HIV infections, and does not say if they collected any such data.

Ethical short-comings

The three studies treated research participants in ways that would not be allowed in the US, Canada, and France, non-African countries that funded the studies:

  • The South Africa study recruited men and the Uganda study recruited wives without insisting they hear their HIV test results. Neither study has said how many participants did not hear their results.
  • The Uganda study followed men who did not know the study had found some of their wives to be HIV-positive (some of the wives also did not know) to watch the men get HIV.
  • None of the studies insisted that men who acquired HIV bring their wives for couple counseling. This ethical lapse – leaving wives with unknown risks – undermined the objective of the research, which was to see how much circumcision reduced sexual transmission.

Study teams for two of the three trials did not register the trials (ie, document what they were planning to do in their human subjects research) before the trial began. Both were registered only after follow-up was completed and less than one month before publication.[11, para 35 in reference 12]

References

1. WHO, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. Geneva: WHO, 2007. Available at: http://apps.who.int/iris/bitstream/handle/10665/43751/9789241595988_eng.pdf?sequence=1 (accessed 2 May 2018).

2. Auvert B, Taljaard D, Lagarde E, et al. Randomized controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS t1265 trial. PLoS Med 2005; 2: 1112-1122. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1262556/pdf/pmed.0020298.pdf (accessed 2 May 2018).

3. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-656. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17321310 (accessed 2 May 2018).

4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized controlled trial. Lancet 2007; 369: 657-666. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17321311 (accessed 3 May 2018).

5. Brewer, D. D., Rothenberg, R. B., Potterat, J. J., Brody, S., & Gisselquist, D. (2004). HIV epidemiology in sub-Saharan Africa: rich in conjecture, poor in data (reply to letter by Boily et al.). International Journal of STD & AIDS15, 63-65. Available at: http://www.interscientific.net/ijsa2004.html (accessed 2 May 2018).

6. Wawer M. Trial of male circumcision: HIV, sexually transmitted disease (STD) and behavioral effects men, women and the community. ClinicalTrials.gov, 2007. Available at: https://clinicaltrials.gov/ct2/show/NCT00124878 (accessed 2 May 2018).

7. Auvert B, Sobngwi-Tambekou J, Taljaard, et al. Author’s reply. PLoS Med 2006; 3: 0141-0143. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360639/pdf/pmed.0030065.pdf (accessed 2 May 2018).

8. Mattson CL, Bailey RC, Agot K, et al. A nested case-control study of sexual practices and risk factors for prevalent HIV-1 infection among young men in Kisumu, Kenya. Sex Transm Dis 2007; 34: 731-736. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17321310 (accessed 2 May 2018).

9. Mattson et al. Sexual practices and risk factors for HIV among young men in Kisumu, Kenya. Available at: http://www.abstract-archive.org/ (accessed 2 May 2018).

10. Makumbi et al. Male post-coital penile cleansing and the risk of HIV-acquisition in uncircumcised men, Rakai District, Uganda. Abstract WEAC1LB, 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Australia, 25 July 2007. Available at: http://www.abstract-archive.org/ (accessed 3 May 2018).

11. Thornton J. Circumcision and HIV. Blog post 18 September 2012. Available at: https://ripe-tomato.org/2012/09/18/circumcision-and-hiv/ (accessed 2 May 2018).

12. World Medical Association. Declaration of Helsinki 2013. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ (accessed 3 May 2018).

Long past time to listen, believe, and investigate


There would be no HIV epidemic if doctors and nurses in Central and West Africa had not reused syringes and needles during 1900-1960. We’d worry about other things. And health aid programs would be begging for money for other things. But no one would have heard of HIV.

The charge – accusation – that colonial health care programs started the HIV/AIDS epidemics does not come from a wacko conspiracy theorist. Jacques Pepin, an accepted mainstream scientist, elaborates the charge in his new book, The Origins of AIDS. Peter Piot, the chairman of the AIDS establishment – the long-term former head of UNAIDS – seconds the charge: “As far as the origins of AIDS are concerned…it will be difficult to come up with a better explanation than Pepin’s. The role of medical injections in the initial spread of HIV in Africa is quite plausible.”

Pepin’s story of AIDS origins begins with hunters and butchers who sometimes get blood from chimpanzees into cuts. On rare occasions, chimpanzee blood infects a hunter or butcher with simian immunodeficiency virus (SIV), at which point we call it HIV (human immunodeficiency virus). But it’s what happens next that’s important. Pepin argues – with a lot of evidence – that sexual transmission of HIV from a cut hunter or butcher to spouses and others was too inefficient – too slow – to sustain a chain of infection among humans. Without unsafe injections to spread HIV, the cut hunter or butcher would have died without spreading the infection. And there would be no epidemic.

But after making sense of the beginning of the epidemic, Pepin, Piot, and the rest of the AIDS establishment tell another and conflicting story. They want us to believe that although sexual transmission was too inefficient to start the epidemic, it later became so efficient that it accounts for almost all HIV infections in African adults. That makes about as much sense as saying pigs can’t take off and fly, but if you throw them into the air, then they can fly.

Mainstream AIDS experts have been persistent for almost 30 years in their claim that almost all HIV in African adults comes from sex. Let’s be clear what this claim means and where it comes from.

The claim is an accusation. Most couples with HIV in Africa are discordant – one is HIV-positive, and the other is HIV-negative. The claim that almost all HIV comes from sex accuses millions of men and women in discordant couples of having sex outside marriage. In discordant couples, women are the HIV-positive partner as often as men. Because women are generally the first partner tested (during antenatal care), the accusation that almost all HIV comes from sex targets especially women. The consequences can be harsh: A recent news story tells of a woman in Kenya who tested HIV-positive during antenatal care, and then brought her husband to test. When he tested HIV-negative, he accused her of being pregnant by another man and threw her out of the house.

Where does the claim (accusation) come from? It doesn’t come from evidence. After 30 years of research, the AIDS mainstream is still unable to point to anything different about sex in Africa that could explain how HIV infects so many people. Studies repeatedly show that sexual behavior in Africa is similar to, if not more conservative than, sexual behavior in Europe or the US. It doesn’t come from models: Models shows that sexual behavior in Africa combined with known rates of sexual transmission could not create Africa’s HIV epidemics.

On the other hand, study after study in Africa finds HIV-positive men and women who report no possible sexual exposures to HIV – such as virgins, and people with an HIV-negative spouse and no other lifetime sex partner. What do AIDS experts do with this evidence? Studies characteristically conclude that those who report no sexual risks got HIV from sex – and then lied about it. No matter what studies find and Africans say, the accusation remains: If you are African, you got HIV from sex.

The accusation that almost all HIV infections in African adults comes from sex not only blames HIV-positive adults for unwise sexual behavior but accuses and stigmatizes Africans in general for unusual sexual behavior and lack of human feelings. It’s a riff on historic characterizations of Africans as sub-human, close to animals, and backward.

Euphemistically, we could call the accusation an hypothesis, or in layman’s terms, a guess. But considering the lack of supporting evidence as well as persistent contradictory evidence, it hardly qualifies as a legitimate hypothesis waiting for tests and proof. It’s a dangerous wolf that masquerades in sheep’s clothing as a respectable hypothesis.

Which brings us to the question: Who gains? Health aid managers, health care providers, and ministries of health across Africa gain by blaming HIV-positive Africans for unwise sexual behavior. The alternative is to accept some of the blame for Africa’s ongoing epidemics. Does unsafe health care spread HIV in Africa today as in colonial times? A lot of evidence says so. To see if it’s so, and to find and stop dangerous health care procedures, ministries of health need to investigate unexpected infections. When a woman is HIV-positive with no sexual risks, it’s unlikely she is the only woman who’s been infected by the responsible clinic. How many were infected – tens, hundreds? Without looking – testing other women who visited the same clinic – we won’t know, and we won’t find the risk and stop the ongoing clinic-based HIV outbreak.

Health care professionals have a common conflict of interest that discourages them from talking about ongoing HIV transmission through health care. This common conflict of interest creates what could be called a natural conspiracy of silence about bloodborne risks for HIV. If any health care professional wants to challenge that assessment, here’s how – Call publicly for investigations of unexpected HIV infections. Show that you, at least, are not part of a conspiracy of silence about HIV transmission through health care in Africa.

Is misogyny misleading the response to Africa’s HIV/AIDS epidemics?


Everyone has prejudices. Trying to overcome them can be like playing the arcade game whack-a-mole. See it, whack it. It pops up again, whack it again. The AIDS epidemic energizes a lot of prejudices. Unfortunately, the international AIDS industry – organizations and individuals getting money to do something about AIDS, including aid agencies, researchers, and others – has not been alert to see and reject common prejudices.

For example, even though careful surveys show that heterosexual behavior in Africa is similar to behavior in the US and Europe, most AIDS experts say that sexual behavior explains Africa’s terrible epidemics. Because the AIDS industry has not yet whacked racial stereotypes of sexual behavior, it has not yet been compelled to look for something other than sex that is different in Africa, and that could help to explain how HIV can infect 5%-26% of adults (50-260 out of 1,000 adults) in 15 countries in Africa compared to only 0.3% of adults (3 in 1,000) outside Africa.

But it’s not only racism that misdirects the AIDS industry’s response to Africa’s epidemics. Another prejudice – misogyny – seems to do so as well. Features of two prominent health aid programs in Africa – circumcising men, and extending birth control to women – suggest that misogyny is a hidden influence.

Circumcision: During 2005-07, studies in Africa reported that circumcising HIV-negative men reduced their risk to get HIV by 53% (median result from three studies), but that circumcising HIV-positive men increased transmission to their wives by 49% (result from one study). Based on these studies, donors initiated crash programs to circumcise millions of African men. Critics point out that circumcised men will still have to use condoms to be safe (not just safer). But since we’re focusing on women, let’s leave aside arguments that mass circumcision is not a good way to protect men.

Let’s focus instead on what was done with the evidence that circumcising HIV-positive men increased their partners’ risk to get HIV by 49%. Notably, in the study that reported that statistic, wives of circumcised men were at especially high risk if they resumed sex before their husbands’ circumcision wound healed – 5 (28%) of 18 who did so got HIV in the 6 months after their husbands were circumcised.

Programs offering subsidized circumcisions could protect wives by requiring that men asking to be circumcised be tested for HIV, and if found to be infected bring their wives for couple counseling before proceeding with the circumcision. Instead, the Joint United Nations Programme on AIDS (UNAIDS) recommends: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative” (quote from page 7 of this link). As mass circumcision programs got underway, as many as 1/3rd of men resumed sex before wound healing. Lack of care to protect women suggests misogyny – or is it just careless incompetence that happens to hurt women?

Hormone injections for birth control: During the last several decades, many studies in Africa and Asia found that women taking hormone (progesterone) injections for birth control were more likely to get HIV compared to women using other birth control methods. A similar risk is found with monkeys: As early as 1996, scientists studying SIV (simian HIV) in monkeys found that progesterone implants multiplied by 8 times their risk to get SIV. Progesterone thinned the monkey’s vaginal wall and enhanced virus replication. Another HIV risk with hormone injections is that careless providers might reuse unsterilized syringes and needles, transmitting HIV from one woman to another.

Despite the evidence, WHO continues to say hormone injections are safe for all women, and donors continue to push hormone injections for birth control – especially in Africa. Outside Africa, 3% of women (partnered women aged 15-49 years) use hormone injections. In contrast, in Kenya, Lesotho, Malawi, Namibia, South Africa, and Swaziland, the percentage of women using hormone injections increased from 6%-20% in 1996 to 17%-29% in 2009. In these same countries, 6%-26% of adults are HIV-positive.

Compare what the AIDS industry does to protect men vs. women: In 2011,  a study among discordant couples (in which only one partner is HIV-positive) in Africa reported that women taking hormone injections for birth control were more than twice as likely to acquire HIV from their husbands compared to women using non-hormone methods. From this data, helping women shift from hormone injections to safer methods would cut their risk for HIV by 54% — as much as circumcision seemed to protect men in several recent studies. How did donors respond? Donors budget hundreds of millions of dollars to circumcise African men, but no donor has committed even one dollar to shift women from hormone injections to safer birth control methods. As of late 2011, the aid-for-family-planning industry, including notably USAID, continues to push hormone injections in Africa.

Other signs of misogyny: Outside Africa, HIV infects mostly men. Where that’s the case, researchers have identified all important risks – most infections come from anal sex among men or from sharing syringes and needles to inject illegal drugs. Knowing their risks helps men to avoid infection and thereby limits the extent of HIV epidemics. Outside Africa, only 0.3% of adults are infected.

In Africa, HIV infects more women than men. In Swaziland, for example, HIV infects 31% of women vs. 20% of men. In the 28 years after AIDS was recognized in Africa in 1983, researchers have failed to do the simple research required to identify important risks for women – that is, to trace the source of their infections.

We know some women get HIV from their husbands. But we also know that in most African countries married women with HIV are more likely to have HIV-negative than HIV-positive husbands. We know that many self-reported virgin women are HIV-positive. We know that reuse of unsterilized medical instruments is common in Africa. So we know some things. But we don’t know enough. Failure to identify women’s risks may well be the key to failure to control Africa’s epidemics.

Other evidence of misogyny comes from the AIDS industry’s frequent  claims that prostitutes drive Africa’s epidemics. Throughout history, societies have blamed promiscuous women — especially prostitutes — for spreading sexually transmitted disease. Some studies in Africa have found a lot of prostitutes with HIV — but how did they get it? Notably, in most countries outside Africa, HIV is rare in prostitutes who do not inject illegal drugs. Few prostitutes in Africa inject illegal drugs, but they get other injections, such as antibiotics to treat sexually transmitted disease. Nevertheless, building on a long tradition, the AIDS industry finds it easy to blame prostitutes’ HIV infections on sex, rather than to investigate to see how much unsafe health care not only infects prostitutes, but also spreads HIV from prostitutes to others.

Finally, consider the different attention paid to sterilization of medical instruments in the Expanded Programme on Immunization (EPI), which began in 1974 and which treats mostly children, compared to what has been done in safe motherhood and family planning programs for women. During the 1980s and later, EPI’s donors arranged dozens of surveys of injection practices in immunization programs. These surveys found lots of unsafe injections. In 1999 a WHO committee acknowledged that 30% of vaccination injections were unsafe. To address the problem, EPI’s donors belatedly shifted vaccination injections to auto-disable syringes, which break after one use.

Unlike EPI, programs promoting health care for women have not arranged surveys to see if health care is safe – e.g., how often are gloves, specula, and syringes reused without sterilization? Even so, there is a lot of evidence that women’s health care in many hospitals and clinics in Africa is not only unreliably sterile but has also infected women with HIV. For example, a 2005 national survey in Ethiopia found that 9.9% of women who gave birth in the last 3 years with delivery care from a health professional were HIV-positive vs. only 1.2% of women who gave birth but did not get such care. We don’t know where all those infections came from. Not knowing shows that no one has cared enough about women to do the simple studies to find the risks – tracing infections to their source – so that women can be warned and thereby protected. Donors’ head-in-the-sand approach to women’s exposures to unsterile instruments in health care mocks the “safe motherhood” slogan.

More than money is required to stop Africa’s AIDS epidemic – it also needs clear thinking.  That is hard to do when common prejudices are not recognized and whacked. If we see and whack racial stereotypes of African sexual behavior, we’re more open to evidence pointing to other explanations. If we’re alert to whack misogyny, we’re forced to take a good look at all the ways the AIDS industry harms and stigmatizes African women. Clear thinking can help to translate good intentions into protecting and healing actions.

HIV Concurrency: Another UNAIDS Sacred Cow Slaughtered


Because we believe that health care and cosmetic services may contribute more to HIV epidemics than is admitted by UNAIDS and the HIV industry in general, we are always concerned when a new slogan or buzzword (or even an old one) dominates the entire global HIV agenda. Examples of these terms are ABC, abstinence, multiple partnerships, polygyny, dry sex, treatment is prevention, test and treat, circumcision, early sexual initiation, and the list goes on.

Our argument is not that we know how significant the contribution of hospital acquired and other non-sexual modes of transmission are to HIV epidemics. Rather, we are calling for the issues to be investigated, with an open mind. And an open mind is something you rarely find in the HIV/AIDS literature. Many papers start with the assumption that heterosexual sex contributes 80, even 90% of all new infections in African countries.

The concurrency theory is the view that many sexual relationships in Africa overlap and that this is an efficient means of spreading HIV. This was one of several possibilities considered by the HIV industry to explain why people all over the world can engage in large amounts of ‘unsafe’ heterosexual sex without that resulting in massive HIV epidemics. Yet, far lower levels of sexual behavior, often far ‘safer’ sexual behavior, in African countries results in rates of HIV transmission that can not be explained by the data we have about transmission probabilities for heterosexual sex.

In another blog, I have collected together and commented on some of the best recent scientific research into concurrency and, as a theory, it has been found wanting. Proponents of the theory are all required to hold, often without stating, a very strong, highly racist and sexist theory about African sexuality, one that has no empirical support whatsoever:

HIV Concurrency Theory is Dead; Can’t You Smell it Yet?

The Sound of a One Legged Argument Kicking Itself

Concurrency Regurgitated: Dubious Evidence Found Increasingly Credible by Experts

Global HIV Policy: Blame, Stigma and Finger-Wagging

Concurrency: the Favorite Plaything of the Sex-Obsessed HIV Industry

Concurrent Relationships: the Latest Stick for Beating Africans

In its entry for ‘sacred cow’, Wikipedia has a particularly apposite citation: “V. S. Naipaul … has the ability to distinguish the death of an ordinary ox, which, being of concern to no one, may be put quickly out of its agony, from that of a sacred cow, which must be solicitously guarded so that it can die its agonizing death without any interference.”

But our concern is not for the theory or the academic hubris that lies behind it; it is for the millions of people who have been infected with HIV when a bit of honesty might have protected them; for those who have already died or transmitted the virus to others because they don’t know how it is spread; and for those who will continue to be infected with or transmit the virus because the HIV industry refuses to investigate the role of health care and cosmetic HIV transmission in high prevalence African countries.

Circumcision is a Joke to Some Researchers, but Do they Know the Risks Involved?


Although it’s reported as good news, nearly one fifth of South African men surveyed thought that circumcision would fully protect them from HIV. The report concluded that “communication and counseling should emphasize what clinical AMC is and its effect on HIV acquisition“. But communication around male circumcision always appears to be lacking. The dangers of being circumcised in countries where safety in health facilities cannot be guaranteed doesn’t seem to be discussed. Apparently, those pushing for more circumcision are satisfied with their own research, though they don’t appear to have looked into the risks involved.

Aside from problems with botched operations, and they do occur, there is a high risk of exposure to contaminated blood through unsterilized medical instruments in many African countries. You may end up in a showcase circumcision program or you may end up being operated on in conditions that most Africans have to face when they attend health facilities for far more urgent operations and care.

However, despite all the enthusiasm for circumcising 20 million men, and the vast claims of numbers circumcised in Kenya (where most men are already circumcised), only 600,000 in 14 countries are said to have undergone the operation during the current program. One commentator says “it’s really, really difficult to bring this to scale“, which is a delicate way of saying that you can’t expect a massive health program to be carried out in a group of countries where health facilities are scarce, underfunded, underequipped, understaffed and in atrocious conditions. Just have a look at a few Service Provision Assessment reports for African countries.

It’s worth bearing in mind that the 60% protection claimed for circumcision refers to sex without a condom; if circumcised and uncircumcised men use condoms properly and all the time, they will both have the same risk of being infected with HIV. It is also worth remembering that while circumcision may give some protection to men (though the evidence is not strong enough to justify the costs and risks), it can increase HIV transmission to women. It is women who are already infected in far greater numbers than men in most high HIV prevalence areas. As many as 5 women can be infected for every 1 man; mass male circumcision may end up increasing overall HIV transmission.

One of the most ardent fans of circumcision for others is Robert Bailey, who has done much of the promoting in Kenya. He said “We’re hacking away at it every month…those foreskins are flying.” This attempt at humor may come back to bite him, because many clinical trials carried out in East Africa have involved practices that are highly questionable, ethically and clinically. It’s not people like Bailey who suffer the numerous but less media friendly health problems that Africans face. But obsession with HIV, African sexuality, circumcision and the like distracts attention and funding from the real issues. Bailey wants 2 billion for circumcision programs while millions of people are infected with and die from cheaply preventable and curable diseases.

Perhaps Bailey himself might enjoy the experience of having an operation in some of the facilities that the UN cannot guarantee the safety of? Perhaps he’d like his family to sample the delights of badly trained clinical officers (like a nurse, but do the work of doctors because there are too few properly trained personnel)? Like all skin piercing procedures in African health facilities, male circumcision can be very dangerous.

Because there is a lot of money involved, no one wants to stand up to this heavy handed approach to the issue. Uganda’s Museveni has said the operation is not scientifically proven to prevent HIV, which is good, but he has also said that ” only premarital abstinence and marital monogamy are sure to work”, which is not true. Most new HIV transmissions occur in long term relationships, that’s been the case for some time, and not just in Uganda either. And that’s the problem with circumcision: lying behind it is the incorrect assumption that most HIV transmission occurs through heterosexual sex. Countries with high HIV rates need to investigate the relative roles of health and cosmetic facility HIV transmission.