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It’s not Condoms that are Failing to Protect Against HIV, it’s UNAIDS

At the beginning of this month, David Gisselquist took a careful look at UNAIDS’ ‘Modes of Transmission’ model and found it seriously lacking, grossly overestimating HIV transmission among couples in long term relationships in Malawi. As a result of this flaw, the model gives results which appear to support the extremely racist view that most Africans in high HIV prevalence countries, male and female, engage in a lot of unsafe sex, and mainly sex with people other than their partners.

David shows how the Modes of Transmission model currently estimates that 81% of Malawi’s 95,000 new HIV infections were accounted for by spousal transmission. If you remove the flaw, the percentage goes down to 20%, leaving 60% of all infections unaccounted for by the model (non-sexual transmissions from mother to child make up much of the remainder). How were all those other people infected, including the women who are said to have infected their babies?

It is very likely that a substantial number of HIV infections in Malawi and other high prevalence countries are a result of non-sexual transmission, such as through unsafe healthcare, cosmetic procedures and traditional practices. The much lauded ‘ABC’ (Abstain, Be faithful, use Condoms) approach to HIV prevention does not work, not because many Africans actually live up to the stereotypical ‘all men are bastards, all women are hapless victims’, but because HIV is not always transmitted through heterosexual sex.

Consider condoms, which are a great technology for reducing unplanned pregnancies, many sexually transmitted infections and sexually transmitted HIV, through anal and vaginal intercourse. But a number of surveys have found that HIV prevalence is very high among those who use condoms. Indeed, prevalence is often higher among those who at least sometimes use condoms than among those who never use them. The following chart is from the relevant Demographic and Health Survey for four countries.

 HIV Prev Condom Use

In some cases, HIV prevalence is 50% higher among those who sometimes use condoms than among those who never use them, sometimes 100%. Shocking? Only if you think HIV transmission in high prevalence African countries is all about sex. Consider another set of figures, this time for condom use at last sexual intercourse in past 12 months. The figures for those who have not had sex in the past 12 months also raise questions (data from DHS surveys). You could suggest that people are not honest, or that people who are infected are ‘abstaining’, but it is far more vital to figure out exactly how people are being infected in order to prevent further infections.

HIV Prev Condom Use 12 Months

Why are HIV prevalence figures so much higher among people who say they sometimes use condoms? I can only tell you what I think; condom use is completely irrelevant to non-sexually transmitted HIV. That sounds obvious, but UNAIDS insist that almost all transmission is through heterosexual sex, yet they stand by figures like these. It is not possible for HIV prevalence to be so much lower among those who never use condoms if almost all HIV transmission is sexual. But there may be an explanation for why those who sometimes use condoms seem so much more likely to be infected.

HIV prevalence is often highest among wealthier, urban dwelling, employed, female, better educated people who live in wealthier countries that have reasonable access to reproductive healthcare services, a relatively low population density and sometimes a higher urban population (but not always). People who answer that description, people who can tick at least some of those boxes (some of the factors are interdependent), it seems, are also more likely to use condoms.

So it is not a case of people with the above characteristics using condoms, yet still being more likely to be infected with HIV, but rather a case of those same people being more likely to be infected with HIV through unsafe healthcare or some other non-sexual route. Once you challenge the sexual behavior paradigm the rest is clear: condoms are irrelevant to non-sexual HIV transmission. It only sounds unintuitive if you keep clinging to the sexist, racist and extremely dangerous reflex about sexual behavior, so beloved by UNAIDS, WHO, CDC, PEPFAR, the Gates Foundation and various universities that have been prominent in the HIV industry.

Given what we so often hear about HIV being inextricably linked with poverty, unemployment, lack of education, isolation, poor access to health services, etc, it is worth emphasizing that the virus may often be more closely linked to the opposite of these factors. Of course, all of these factors are abhorrent and it should be the aim of every wealthy country to ensure that such conditions are alleviated. But if HIV is being transmitted through unsafe healthcare and other routes, all healthcare development must be SAFE healthcare, all HIV education must include information about non-sexual transmission, all employment and environments must exclude risks of bloodborne transmission of HIV, as much as possible.

So first we need to recognize that HIV is not solely transmitted through ‘unsafe’ sex and that it can be transmitted, perhaps far more easily, through unsafe healthcare, cosmetic procedures and traditional practices. ABC ‘strategies’ do not work because HIV transmission is not all about sex, not because Africans are too careless, promiscuous or ignorant (or even ‘disempowered’) to follow its patronizing advice. Safe sex has its place, but safe healthcare is a far more urgent issue in high HIV prevalence African countries right now. It’s not condoms that are failing to protect people against HIV, but the intransigence of UNAIDS and the rest of the HIV industry.

UNAIDS’ 3 Ones: One Disease, One Theory, One Solution

According to “more than $400 million [of donor funding] was committed to HIV and AIDS in 2007/2008“. However, less than a quarter of that funding, probably around 20%, was spent on ‘prevention’, with the usual assumption that almost all HIV is transmitted through heterosexual behavior. Around 60% is estimated to have been spent on treatment and care, say around $240 million.

It’s tremendous that a lot of money is being spent on treating and caring for people who have been infected with HIV. Not all HIV positive people are currently eligible for treatment. Perhaps UNAIDS’ claim that 60% of those who are eligible were on treatment at some time, although the figure, however many hundreds of thousands it may be, does not discount those who have died or who have been otherwise lost to follow up.

Around 95% of Tanzanian people are HIV negative. Out of the 1,470,000 people who are living with HIV, between one and two thirds may be on treatment. That’s 1-2% of Tanzanian people, at the most. So how do those who control the money decide how to spend the approximately $80 million in order to reduce transmission of HIV; what kind of prevention activities should be prioritized among those 46,300,000 Tanzanians who are still uninfected?

UNAIDS has a slogan (aside from their ‘three ones’ slogan alluded to in the title above) that goes ‘know your epidemic – know your response’. This makes it sound like UNAIDS believes that there are different epidemics in each country, and perhaps even different subepidemics within each country. But their response is always to treat HIV epidemics in Africa as if they are all virtually the same, although they may vary in intensity: but they are all assumed to be ‘driven’ by heterosexual behavior.

It’s not very clear how far $1.70 per head can go towards ‘changing people’s sexual behavior’, but that hasn’t stopped UNAIDS and other big players in the HIV industry (and some of them are very big players indeed) from trying. Billions have been spent on wagging fingers at rooms full of adults and children over the almost 20 years of UNAIDS’ existence.

Luckily there are a few things that can be done to help establish that HIV is probably not entirely heterosexually transmitted and that most finger-wagging exercises are a complete waste of money (their inherent paternalism is probably not considered to be a disadvantage; perhaps neither is their clearly demonstrated ineffectiveness).

For example, in Tanzania (and most other countries) there are only a few places where HIV prevalence is really high. Here’s a list of prevalence by region (the five with the lowest prevalence are the Zanzibar archipelago):

Njombe 14.8
Iringa 9.1
Mbeya 9
Shinyanga 7.4
Ruvuma 7
Dar es Salaam 6.9
Rukwa 6.2
Katavi 5.9
Pwani 5.9
Tabora 5.1
Kagera 4.8
Geita 4.7
Mara 4.5
Mwanza 4.2
Mtwara 4.1
Kilimanjaro 3.8
Morogoro 3.8
Simiyu 3.6
Kigoma 3.4
Singida 3.3
Arusha 3.2
Dodoma 2.9
Lindi 2.9
Tanga 2.4
Manyara 1.5
Mjini Magharibi 1.4
Kusini Unguja 0.5
Kusini Pemba 0.4
Kaskazini Pemba 0.3
Kaskazini Unguja 0.1

And there are further generalizations that can be made about HIV in Tanzania. Prevalence tends to be higher among females, urban dwellers, wealthier people, people with higher levels of education and employed people. It tends to be lower among men, rural dwellers, poorer people, people with lower levels of education and unemployed people.

UNAIDS tends to ‘analyze’ these features, which are shared by all high HIV prevalence countries, and conclude that wealthier, urban dwellers with jobs have bigger ‘sexual networks’ (etc) as if every person with HIV must have a ‘sexual network’ (etc). But there are other figures they could avail of when they are in an analytical frame of mind.

For example, while women are said to be more susceptible to HIV infection for various biological reasons, wealthier, urban dwelling, better edcated women with a job are also much more likely to attend ante natal clinics (ANC) and seek the assistance of some kind of trained health professional when they are giving birth.

Now, you might expect women who attend ANCs and have assisted deliveries to be less likely to be infected with HIV, but you’d be wrong. In many instances they are more likely to be infected, sometimes a lot more likely. Indeed, some countries with the highest HIV prevalence figures also have the highest ANC and attended birth figures, Swaziland, Lesotho, Namibia and Zimbabwe, for example. The contrary tends to be true of low prevalence countries in sub-Saharan Africa.

This is not to say that HIV is never transmitted through heterosexual sex, or that it is always transmitted through unsafe healthcare (even among women). It’s just a clear indication that we need to know exactly what contribution heterosexual behavior makes to epidemics, and what contribution may be made by non-sexual routes, such as unsafe healthcare, cosmetic care and perhaps other practices.

The whole concept of a UN agency set up to ‘fight’ one disease is bad enough. But it’s a whole lot worse if they and the rest of the industry continue to squander precious resources on poorly targeted and ineffective interventions. Resources need to be spent on health, defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (there’s no irony intended in citing WHO here).

Apparently one third of all aid in Tanzania is being spent on HIV, which leaves the other two thirds to be spent on other development areas. So perhaps some of that will eventually be used to address the many poorer, less well educated, jobless people living in rural areas with virtually no infrastructure or social services, but who are HIV negative. They will likely remain negative if even a fraction of available donor funding is spent on working out the relative contribution of unsafe healthcare to the worst HIV epidemics in the world and addressing this issue, however belatedly.