When a PrEP trial produces poor results, the reaction is often to point the finger at the patient: they didn't take the drugs regularly, 'adherence' was low, etc. The irony of this is that people thought of as good candidates for PrEP are often those who have not successfully modified their Sexual Behavior, or have shown themselves unwilling to do so. If they will not or can not modify their sexual behavior, why would they be more willing or able to modify their drug taking behavior?
Some drug trial reports parcel up the high achievers and exclude the low and medium achievers and call it a 'sub-study' or something similar. But the point of a randomized controlled trial is to make it clear what kind of result can be expected of people taking part, not what kind of result can be expected if everyone behaved as drug manufacturers would wish them to. Given that people don't behave in real life as they do during drug trials, the results for strategies such as PrEP so far have been somewhat encouraging, but not good enough to roll out the strategy.
Even with PrEP, people are encouraged to engage in safe sex, to limit their number of partners, to use condoms, etc. If they can't or won't do some or all of those things, PrEP will not be very effective; but it may not have any positive impact at all. Those behind the trials and those producing the drugs are anxious to portray the strategy as tested and proven, but it is most definitely not, not yet anyhow. One of the main exponents of the strategy tries to persuade us that PrEP is the way to go, but some of his readers are clearly not convinced. And the opposing case raises additional concerns about PrEP, referring to the strategy as 'grasping at straws'.
In countries where HIV prevalence is very high and transmission is highest among low (sexual) risk groups, those engaging in heterosexual sex with one HIV negative partner, PrEP is not going to be feasible. Those who face the lowest risk, but are paradoxically the highest risk group in Modes of Transmission Surveys, are unlikely to be targeted by a PrEP campaign.
And given that the majority of HIV positive people in need of treatment are still not receiving it due to cost, infrastructure, political and other reasons, it would be odd to offer the same drugs to people who are still HIV negative. It would seem far better to establish what exactly the risks are and address those risks before throwing yet more drugs at the problem. But PrEP is the way to go if you want to sell lots of drugs to healthy people; if that doesn't work, you'll then have lots of sick people to sell even more drugs to.Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Thursday, 9 August 2012
Randomized Controlled Trial-Drug Manufacturers-Sexual Behavior-Drug Trials
Tuesday, 5 June 2012
Food And Drug Administration-Aids Healthcare Foundation-Poor Efficacy-Truvada
In addition to the good work that the Aids Healthcare Foundation is doing to question the 'fast-tracking' of the use of Truvada as PrEP when it has so far shown such poor efficacy, a group of 55 US physicians have signed a letter, also urging the US Food And Drug Administration (FDA) to delay approval until further tests, which may take years, have been carried out.PrEP may be a great theory and Truvada may be a great drug. But there is little to get excited about yet. If effectiveness in the real world (as opposed to efficacy in carefully controlled trial contexts) can reach a reasonable level, which would be a lot higher than the unimpressive 44% found in the iPrEX study, then it will be time to consider the use of Truvada as PrEP.It's good to hear that some doctors are standing up for their patients. Others appear to be in the thrall, or in the pocket, of Big Pharma. Many AIDS and human rights activists seem to have got the wrong end of the stick on this one: people have a right to safe healthcare, not to be used as free lab-rat material.Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Monday, 4 June 2012
Retraction: 127 Zimbabwean Women-Antiretroviral Drug-HIV
Following an article in ZimEye.org, I mistakenly wrote that one arm of the Vaginal and Oral Interventions to Control the Epidemic (VOICE) trial, involving the antiretroviral drug Tenofovir, was stopped because 127 women taking the drug became infected with HIV. In fact, these women were taken out of the trial because of 'futility', the finding that it would not be possible to show that the treatment they were receiving was more effective than the placebo that another group was receiving.I apologise for reporting something so alarmist when the only source was an online article (which apparently also appeared in the Sunday Mail) that was released without any named author. I will take more care in commenting on such articles in the future. I have removed my blog post from the three sites where I placed it and will make the same efforts to publicize this retraction as I made with the original.There will be a press release confirming the above, which I will post as a comment to this report as soon as it is available.Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Saturday, 19 May 2012
Pre-Exposure Prophylaxis-African Countries-Hiv Negative-HIV
Apologies for the lack of posting this year but I have had enough work keeping my other blog going. The subject of PrEP and related issues do also crop up there, though.
Daily use of Truvada has been backed for pre-exposure prophylaxis use by a panel of 'experts', which generally refers to people who are so well paid to say the right thing that no one else will disagree with them. It's likely that this use of the drug will soon be approved by the FDA. I wasn't able to find a register of the 'experts'' interests but I'm sure it would make interesting reading.
If approved, the drug will be prescribed for HIV negative people who are thought to be at high risk of being infected sexually, which generally refers to men who have sex with men in Western countries. The drug is not being considered for use by intravenous drug users. It is also unlikely to be of much value for commercial sex workers in wealthy countries as they are rarely infected unless they are also intravenous drug users or face other serious risks.
This suggests that PrEP is unlikely to be effective in high HIV prevalence developing countries, where high risk groups are not easy to identify. In many African countries, the bulk of infections among adults occur in married people and those in long term relationships, who don't face very high sexual risks. In other words, the drug is of little use as PrEP where it is most needed. But I'm sure that won't stop Big Pharma from lobbying the right people so that the potential tens or hundreds of millions of Africans can be exploited.
The process of palming off useless but extremely expensive drugs with potentially dangerous side-effects on Africans has been eased by years of publicity for the dominant HIV transmission paradigm, which says that almost all HIV in African countries is transmitted through heterosexual behavior. The fact that the paradigm is seriously challenged by empirical data has done little to influence policy, which concentrates on the politician, religious leader and media friendly process of wagging fingers, pointing fingers and poking fingers into the many HIV fuding pies.
Opposition from groups who claim to represent the interests of HIV positive people has almost all been taken care of in the time honored fashion of paying off anyone who speaks out of turn (or rubbishing anyone who won't take payment). A rare voice of dissent comes from the Aids Healthcare Foundation, which has consistently opposed the current trend of rushing into practices which have little empirical backing, but which mysteriously receive full backing from 'experts'.
Pharmaceutical front group Aids Vaccine Advocacy Coalition (AVAC), predictably, blow the trumpet for PrEP; pharmaceutical products ostensibly produced to treat illness would never have become as profitable if they were only used by sick people. But the UK's Nick Partridge puts his finger on the problem, probably inadvertently: "But we need to know if people at highest risk of infection are prepared to take a pill every day and whether there would be an increase in risk-taking behaviour which could outweigh the prevention effectiveness of Truvada."
The truth is, we don't know who is at highest risk in high prevalence countries, we know that most will not take the pill every day and it's very likely there will be an increase in risk-taking behavior, especially where people opt for PrEP because they know (or even think) they are at risk.
[For more about non-sexual HIV transmission and male circumcision, see the Don't Get Stuck With HIV site.]Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Tuesday, 20 March 2012
Hiv Positive-HIV Patients-Prevention
In the light of current enthusiasm for 'treatment as Prevention (or 'is' prevention or some other permutation)', it's sobering to read an article from the US entitled 'Only 28% of HIV patients have condition under control'. The idea of treatment as prevention, sometimes referred to as 'test and treat', is that it will be feasible to test about 80% of an entire population, not just once in a while, but regularly, perhaps once a year or more. Upon being found Hiv Positive people will receive immediate treatment, regardless of clinical stage.The US spends over $7,000 per capita according to WHO estimates for 2009; that's over 15% of GDP. Tanzania, in contrast, spends $57 per capita, 4.5% of GDP. So if only 28% of HIV positive people in the US are rendered unlikely to transmit the virus to others through having a low viral load, at least through (safe heterosexual) sex, and about 20% of those infected don't even know they are positive, where does this leave countries like Tanzania?Figures for how many Tanzanians are on antiretrovirals vary a lot and are vague; they don't make it clear what percentage on treatment have the virus under control. Quite a lot of people said to be on treatment are lost to follow-up every year. Many die or move to another area, but this also suggests that numbers on treatment are overestimated as some are registered in more than one place. The majority of HIV positive people in Tanzania are not on treatment and a majority of the population have never been tested for HIV. A large number of people who have never been tested are estimated to be HIV positive.I just don't feel convinced that the money is going to be stumped up to test tens of millions, perhaps hundreds of millions of people every year for the foreseeable and to treat tens of millions for several decades to come. But perhaps I'm just a sceptic (or 'skeptic' if you're in the US).Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Monday, 19 March 2012
Antiretroviral Drugs-Clinical Trials-Hiv Epidemics-Perspective-HIV
I've found an uncharacteristically sensible article on PrEP, although it's written from a US perspective. It concludes that "Findings from the randomized clinical trials that PrEP is efficacious should mark the beginning of the policy discussion, not its end."The article also demands proof of desirability and even deliverability of PrEP before the strategy is implemented. The authors note that sustained and effective counseling is a must to ensure proper adherence to the drugs and that the level of counseling required, which makes up a major part of clinical trials, is unlikely to be part of a community implementation.Also noted are the lengths that researchers had to go to in order to retain participants in the iPrEx trial, an aspect of such trials that is rarely mentioned when reports of standing ovations at expensive pharmaceutical sponsored conferences come out. The odds during the iPrEx trial seemed to have been stacked against getting a poor result. And yet the result was pretty unimpressive.The article covers a lot of interesting aspects of PrEP that are rarely mentioned among the post trial hype, such as development of resistance to antiretroviral drugs, increased 'unsafe' sexual behavior among some who think PrEP will give them 100% protection and the sheer cost of such a program that provides drugs for uninfected people when there isn't even enough funding for those who are infected.But the article, perhaps being written from a rich country perspective, doesn't mention how spectacularly unsuccessful we have been in identifying 'core transmitters' of HIV in developing countries. In fact, any group that could be considered to be contributing significantly to HIV epidemics in high prevalence African countries is dwarfed by the percentage of infections that are said to come from 'low risk' groups.In short,if PrEP ever proved itself to be feasible in high prevalence African countries, we wouldn't have the faintest idea where to start.[For more about HIV and risk, see my other blog, HIVinKenya]Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Sunday, 4 March 2012
Food And Drug Administration-Pre-Exposure Prophylaxis-Transmission Of Hiv-Favorable Findings
A few days ago, an article appeared on AidsMeds.com about the drug Tenofovir being associated with an increased risk of irreversible kidney disease, which does not reverse even when the drug is no longer taken. Tenofovir is one of the main ingredients in a vaginal gel developed to reduce the Transmission Of Hiv, although a recent trial was stopped early because the gel was found to be ineffective. Another trial of Tenofovir taken orally as pre-exposure prophylaxis was also stopped early as it was clear it would not be possible to demonstrate a difference in effect between the drug and a placebo.Despite these findings, Poz.com reports that the US Food And Drug Administration (FDA) has accepted an application from the makers of Tenofovir, Gilead Sciences, to give a priority review of the use of the drug, in combination with emtricitabine, to be marketed as Truvada. Despite some less favorable findings about Tenofovir, the more favorable findings led to immediate calls for application for use as PrEP to be fast-tracked.In addition to the above worries about Tenofovir, widespread use of PrEP is also likely to give rise to drops in use of condoms. This possibility is denied vigorously by defenders of PrEP, and some data has been produced to support that defence. But like male circumcision and the hormonal contraceptive Depo Provera, people tend not to think about dual protection against both HIV and unplanned pregnancy.Interestingly, while injectable versions of Depo Provera and similar methods are said to be 'female controlled' relative to the oral version, this objection doesn't appear to be used or alluded to by proponents of PrEP or vaginal gel.A paper has been published discussing these diverging trial results and the authors pay particular attention to adherence to the drug regime, which needs to be very high. The authors mention identifying "optimal populations for PrEP"; but they may find that these populations are least likely to need the drug. It's all beginning to sound like a product in search of a market; but where would Big Pharma be if it never took that approach?Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Saturday, 3 March 2012
Hiv Prevention Programs-Sexual Transmission-Hiv Transmission-Hiv Infection
The Microbicide Trials Network (MTN) have announced that Tenofovir gel will no longer be used in the current VOICE trial (Vaginal and Oral Interventions to Control the Epidemic) shortly after the same decision was made about the oral version. Both arms of the trial have been stopped for the same reason; neither are any more effective than a placebo. Trials of Truvada, a combination of tenofovir and emtricitabine, will continue for the moment.Incidence, the rate of new infections, was extremely high, at 6%. I wonder if the trial has got any closer to figuring out just why HIVTransmission is so high among study participants? For instance, were sexual partners tested and were their HIV types matched? Were possible non-sexual HIV exposures investigated, for example, through unsafe healthcare, traditional healthcare, cosmetic practices, or any others?All the talk about 'fast-tracking' approval of tenofovir by the US Food and Drugs Advisory for possible production by 2014 that we heard so much of just a year ago has been replaced by the kind of silence we've come to expect from results that can't even be dressed up to look a little bit positive. With viable gels and PrEP pills so far in the future, it might be a good idea to put into effect some low technology (though far less lucrative) HIV prevention programs.The full results of VOICE are unlikely to be available for some time, perhaps another year or two. But if good data is collected on non-sexual transmission, the thousands of participants will not have wasted their time completely. It won't be much consolation for the hundreds of people whose infections were not prevented, nor the hundreds of thousands of new infections that will occur elsewhere in the meantime, but everyone will benefit if a little less attention is paid to their sex lives, which may not be as relevant as orthodox HIV theory suggests.Mitchell Warren, the Executive Director of the AIDS Vaccine Advocacy Coalition (AVAC, a front group for the HIV pharmaceutical industry), has expressed disappointment. One researcher is reported to have said "the failure of one method in one trial did not mean that the trial, or the idea of microbicides, had failed." Which is quite true. The failure could be for entirely different reasons, incorrect and unwarrented assumptions about the relative contribution of sexual transmission in serious epidemics being just one.Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from Hiv Infection. read more..
Wednesday, 29 February 2012
Pharmaceutical Industry-African Countries-Hiv Infection-Avac-HIV
Pharmaceutical industry front group AVAC is blowing the usual trumpet for PrEP because some recent trial results have been encouraging. They said predictably little about results which were not so encouraging.The problem with PrEP still remains: no high prevalence country has managed to put all HIV positive people on antiretrovirals, not even all those who are at the stage of disease progression where it is a serious threat to their health. Why does anyone think they can roll out a drug for people who are not infected with HIV on the grounds that it might give them 'up to' 73% protection?If 20% of sexually active people are infected with HIV and most of the other 80% are considered to be at risk of infection, will they all be given PrEP? Think of the cost, the logistics, the high levels of resistance, the side effects, things instititutions like AVAC and UNAIDS don't seem to be willing to discuss sensibly.It also seems like a humiliating climbdown for UNAIDS and all the others who maintained that HIV is almost always spread through unsafe heterosexual sex in African countries (though hardly ever in non-African countries, however unintuitive that may sound). Are all 'risk reduction' strategies now to cease?Will we instead just give out drugs and ignore the things we appeared to deplore for the last thirty years, promiscuous men, survival sex, commercial sex work, exploitation, early and unplanned pregnancies, early marriage, concurrent relationships, large numbers of partners, low use of condoms, lack of family planning and whatever other issues we have spent so long bemoaning?Warren Mitchell from AVAC remembered to thank the trial volunteers, presumably mostly guinea pigs who, if they are African, will never be able to afford the drugs and for whom the money to pay for them may never be raised. I don't suppose he was being ironic, either.Another move which looks suspiciously like a way to vastly increase the volume of ARV drug sales, and thereby increase dependency on drugs and funding, is a strategy called test and treat (or various other names). This involves testing the whole population of a country regularly, perhaps every year, and putting everyone found positive on treatment.Testing even a reasonable percentage of people in a population once has remained elusive, let alone the whole population or the whole population every year. But even testing once a year is not thought to be enough, so test and treat is still just a theory. And it is well known that early treatment carries a lot of risks that have not yet been adequately explored.It is to be wondered if people will be obliged to take the drugs by law or if they will face stigma if they refuse. UNAIDS has many years of experience in the use of stigma as a weapon with which to threaten people and punish them for being African so perhaps they have some plans in this area. No disease has ever been beaten by drugs alone so it seems hard to believe that HIV will be the first. But it is great news for the pharmaceutical industry.[For more about PrEP and HIV issues in Africa, see my other blog, HIV in Kenya.]Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from Hiv Infection. read more..
Hiv Prevention Efforts-Transmission Of Hiv-Prevention Strategy-Hiv Transmission
It's a relief to hear that there are some people working with HIV who are willing to speak out against the apparent assumption that treatment is Prevention, that all we need to do is substantially increase the number of people taking expensive antiretroviral therapy (Art) for the rest of their lives, regardless of the known consequences of such a strategy, and HIV transmission will magically decline and eventually disappear.Alison Rodger, Andrew Phillips and Jens Lundgren recommend that before adopting ART as a prevention policy, we need to assess the risk of HIV transmission through unprotected sex (ie, without a condom) when the viral load is undetectable. So far, research has revealed that transmission could be unacceptably high under such circumstances, but neither the media nor the academic hype around treatment as prevention has alluded to this.Xiaohua Tao, Dan Shao and Wei Xue call for an assessment of how a policy of treating HIV positive people at an earlier stage of disease progression would affect their sexual behavior. They point to evidence that use of ART increases risky sexual behavior. They also express worries about the development of resistance to ART, which is one of the known consequences alluded to above.Enthusiasts of the treatment as prevention strategy, Myron S. Cohen, Ying Q. Chen and Thomas R. Fleming, accept that the benefits of ART are unknown where condoms are not used as part of the strategy. They also note the frequent occurrence of pregnancy and sexually transmitted infections (STI) among trial participants, which suggests that self-reported sexual behavior was not so accurate, or that condoms are a lot less effective in reducing STI transmission and pregnancy than we are led to believe.Essentially, Cohen and colleagues are a bit vague with one of the real worries about a treatment as prevention strategy: the lack of clarity about how HIV is transmitted so rapidly in only some countries. The orthodox view is that heterosexual sex is responsible for 80-90% of transmission. But why should a virus that is difficult to transmit through penile-vaginal sex be transmitted so rapidly in certain populations? Do they all secretly engage in anal sex? Or are there non-sexual risks that some of them face?Uganda is an interesting case in point. The orthodoxy gather up lists of 'most at risk' people, men who have sex with men, intravenous drug users and the like. They also add in sex workers, truckers and other groups who are said to be vulnerable because of their 'mobility', whatever that may mean. But there is always the assumption that heterosexual sex is the key. Yet none of these circumstances explain massive rates of transmission in some countries, where most people don't fall into any of those groups said to face high risks.Indeed, the majority of transmissions in Uganda and other countries are among people who do not face high risks, they fall into low risk categories, even by the strictures of UNAIDS and others in the industry. Don't these astute people notice the contradiction in their claims, that most HIV transmission occurs among low risk people, those who do not have high risk lifestyles? What is it about Ugandans? Is it their sex lives, their sex organs, or something else?It's not just treatment as prevention or any other smug strategy that will fail if we don't make it clear how HIV is being transmitted, why it is being transmitted amongst people whose ostensible risk behavior levels are low and why doling out ever increasing amounts of drugs to ever increasing numbers of people should make any difference; because, so far, for every person put on drugs, two become newly infected. If putting 6 or 7 million people on ART doesn't reduce transmission, why should doing so with 16 or 17 million, or more?Treatment is not prevention and until the actual modes of transmission, rather than assumed modes of transmission, have been properly assessed, HIV prevention efforts in Uganda and el read more..
Thursday, 23 February 2012
Hiv Positive-Hiv Negative-Condoms-Arvs-HIV
It is very reassuring that a commentator in Kenya has mentioned, albeit briefly, that providing ARVs to HIV negative people will strain resources in a country where it is not even possible to supply all HIV positve people with them.Many people don't have food, water, cheap drugs for everyday, but deadly, diseases, contraception and family planning, proper education, infrastructure, and a great many other things. Why the obsession with grossly overpriced drugs that will not make any material differenc to most people's health?But there are some odd remarks in the article. One person mentioned in the article that she had not had sex with her husband for the first three years after finding out that he was HIV positive. Then she started to use Condoms.So far so good. Condoms give a good level of protection if they are used properly and used all the time. There are all sorts of stories about condoms breaking but this should be rare if people really know how to use them properly. And at least condoms are cheap and have other benefits, protecting against sexually transmitted infections and preventing unplanned pregnancies.But the article is about using drugs to reduce HIV transmission. This would be in the form of pre-exposure prophylaxis (PrEP), where a HIV negative person takes an antiretroviral drug regularly to reduce the probability of being infected, or 'treatment as prevention', where the HIV positive person takes ARVs which reduce the viral load to a level where HIV is a lot less likely to be transmitted.If condoms are used, is the risk that the HIV negative partner faces going to be reduced further when they also take PrEP? Perhaps so, perhaps a belt and braces policy gives more protection.But if the HIV positive partner is on ARVs, taking them correctly, responding to them (to the extent that their viral load is low, etc), does the HIV negative partner need to be taking PrEP? Couldn't the HIV negative partner just make sure that condoms are used?The more important questions are about whether there will be enough money for all HIV positive people to receive the drugs and other care they need, as well as for HIV negative people to receive the most effective prevention assistance available.Currently, only 20-40% of people in need of ARVs are receiving them. Will the need for PrEP be given priority over the need for ARVs, given that PrEP is for people who are healthy and normal ARV treatment is for people who are sick and will die without the drugs?But even 'treatment as prevention' is not that straightforward. The majority of people in most African countries do not know their HIV status. Even the majority of HIV positive people do not know their status. How easy will it be to identify all HIV positive people and keep on identifying new infections for as long as they occur.Apparently Swaziland is going to test its entire population and put everyone found to be HIV positive on ARVs, effectively, 'treatment as prevention' or 'test and treat'. There are only 1.2 million Swazis but an estimated 200,000 of them are HIV positive.Yet only about 60,000 HIV positive Swazis are on ARVs and the country doesn't even have enough supplies for them. Similar shortages have occurred in other African countries. Health services can barely cope with keeping a fraction of people on treatment, let alone all those who need them.The Kenyan article continues with the sort of honesty that you wouldn't normally find in an article about HIV: prevention so far has had little impact and the rate of new infections is still very high; sexual behavior change, the main aim of most prevention programs, has not occurred to any great extent.But UNAIDS and the HIV orthodoxy have, according to the article, been targeting the wrong people all along. They have been talking about reducing numbers of partners, using condoms and even giving up sex altogether. But many new infections occur in mutually monogamous couples, often among people who tak read more..
Wednesday, 22 February 2012
HIV Infections-Hiv Prevention-Hiv Prevalence-Hiv Infection
Why do so manyHIV-positive children in Africa have HIV-negative mothers?Forexample, approximately 30% of HIV-positive kids aged 0-11 years haveHIV-negative mothers in Mozambique (see pp. 177-181 in:http://www.measuredhs.com/pubs/pdf/AIS8/AIS8.pdf).Why are so manyvirgin men and women found with HIV? In the Republic of Congo,for example, virgin women aged 15-49 years have higher HIV prevalencethan all women, 4.2% vs 4.1% (see p. 101 in:http://www.measuredhs.com/pubs/pdf/AIS7/AIS7.pdf).The personal storiesbehind these statistics are hard to fit with the common view thatalmost all infections are from sex. Why has there been so littleattention and response to Africans with unexplained infections?THE PURPOSE OFTHIS NOTE IS TO INITIATE DEBATE ABOUT WHETHER TO CONTINUE TO IGNORENON-SEXUAL HIV Infections IN AFRICA. To do so, this note presentsfour arguments for AIDS activists, both in Africa and elsewhere, torecognize and respond to HIV from skin-piercing procedures in Africanhealth care and cosmetic services.1.DE-STIGMATIZING HIV/AIDS: Programsfor HIV prevention in Africa – including especially foreign-fundedprograms -- focus almost exclusively on sex. With all attention onsex, the emotions, prejudices, and controversies around sex naturallyspill over into HIV programs. Thus, it is not only wrong to thinkthat all African HIV comes from sex (see points 3 and 4, below), butalso confusing and distracting. Currently, stigma against HIV is sogreat that most people with unexplained infections keep silent, so asnot to be accused of sexual behaviors that some people don’t like.When the public discourse is corrected to recognize blood-borne aswell as sexual HIV (see: http://dontgetstuck.wordpress.com),people with HIV from blood risks will be able to speak out withoutfacing stigma compounded by charges they are lying. And they willthen be able to contribute to public efforts to make health care andcosmetic services safe. 2. PREVENTING HIVINFECTIONS: Ensuring that medical facilities are safe willnot only prevent HIV infection but also the transmission of otherblood borne pathogens. Across Africa, HIV prevalence is lower incountries where more people are aware of blood-borne risks for HIV;see: http://dontgetstuck.wordpress.com/africans-aware-of/3. SEX ALONECAN’T EXPLAIN AFRICA’s HIV EPIDEMICS: Allattempts to explain Africa’s epidemics as exclusively sexual havefailed to find anything that is so different about sex in Africa thatcould account for Africa’s high rates of HIV prevalence.Studies find that Africans have fewer partners and use condoms morethan Americans and Europeans. Circumcision is lesscommon in Europethan Africa. Sex can’t explain how HIV prevalence is lower afterlong term wars, and among people living further from health clinics.Sex is a risk for HIV because so many Africans are infected – buthow are so many infected? 4. EVIDENCE THATAFRICANS GET HIV FROM SKIN-PIERCING EVENTS: Alot of evidence shows HIV transmission through skin-piercingprocedures in Africa.Evidence is both old and new. For example:(a) In 1985, ProjectSIDA in Kinshasa,Zaire(now the Democratic Republic of Congo), tested inpatient andoutpatient children aged 1-24 months and their mothers for HIV.Seventeen (39%) of 44 HIV-positive children had HIV-negative mothers.Among children with HIV-negative mothers, “medical injectionsseemed to be the most important risk factor for HIV…” The studyteam noted, “Injections are often administered in dispensarieswhich reuse needles and syringes yet may not adequatelysterilize them” (Mannet al, Riskfactors for human immunodeficiency virus seropositivity amongchildren 1-24 months old in Kinshasa, Zaire. Lancet1986, ii: 654-7. p. 656.)(b) Around 1990,WHO’s Global Programme on AIDS coordinated a study in Rwanda,Uganda,Tanzania,and Zambiato test in-patient children 6-59 months old and their mothers forHIV. Sixty-one (1.1%) of 5, read more..