Is Most HIV Spread By Sex? No, But Billions of Dollars Say Otherwise

Most of the billions of dollars currently being spent on HIV go to treating and caring for those already infected. A small amount is being spent on 'preventing' HIV but most of that is targeted at sexual transmission, despite the evidence that this is not the only type of transmission. It may not even be the most common type of transmission.

My remarks apply to African countries because that's where HIV epidemics are worst, where most HIV positive people live and where most people at risk of being infected live. It's where HIV, rather mysteriously, almost always spreads through heterosexual sex, while everywhere else in the world it mainly spreads through anal sex and injecting drug use.

One third of research and development funding for over 30 'neglected' diseases is spent on HIV, according to the G-Finder report by Policy Cures, an 'independent' group that happens to rub shoulders with some of the top HIV industry and pharmaceutical players. None of the money spent on HIV R&D is being spent on nosocomial or iatrogenic transmission, transmission that occurs as a result of unsafe medical treatment. HIV drugs, whether they are pre-exposure prophylaxis (PrEP), microbicides, vaccines or antiretrovirals, are aimed at sexual transmission.

In fact, HIV, TB and malaria R&D funding accounts for more than two thirds of all funding, amounting to over two billion dollars a year. Conditions that maim and kill millions of people every year, such as water-borne and food-born conditions, only receive a fraction of this amount. (Although it's interesting to note that the authors of the report are aware of the significance of diarrheal diseases.)

As for provision of clean water and sanitation which would reduce incidence of all of these conditions, this is not even discussed in polite circles.

Developing health services and facilities is not much discussed either. Pharmaceutical and other companies competing for billions of what is, after all, public money, know that if money was spent on health services and facilities and improving access to them, they would end up with far fewer customers.

So, there is no evidence that HIV is almost always transmitted sexually, even in African countries. But an awful lot of money is being spent on 'preventing' sexual HIV transmission while next to none is being spent on non-sexual transmission. And being able to talk about sex and promiscuity is quite a blessing for an otherwise sterile industry. So don't expect attitudes to change quickly.

[For more about nosocomial and iatrogenic HIV transmission, see my other blog, HIV in Kenya.]

Your Solution Is The Problem, Mr Gates

Bill Gates seems to write at least some of this own materials. His 'annual letter' reads as you'd expect it to read if written by someone who has little understanding, of and probably little interest in, development. His priorities are high profile issues and his 'solutions' are high technology and narrowly focused. But development issues and appropriate measures to improve conditions are not isolated phenomena, they also have a context.

Gates' grasp of public health is particularly weak. He seems to think that a handful of diseases can be eradicated, without any attempt being made to improve the conditions that result in those diseases remaining widespread, often after decades of work and billions of dollars spent. He wants to eradicate polio and prevent cholera, for example, without ensuring that people have access to clean water and sanitation.

An article in Science and Development Network picks up on Gates' comments about the 'slow pace of progress' in fighting AIDS. In the case of treatment and care for HIV positive people, he probably has a point, although he seems to think this area is doing well. Yet, in high prevalence countries, only a minority are receiving the care they need and most of them are lucky to receive drugs, which are of limited value on their own.

The pace of progress in HIV prevention is even more lamentable, but I don't really see Gates and his Foundation doing much about it. He seems to think that if drugs and a few other things rain down from the heavens, everything will be fine. He doesn't seem to see the need for health facilities, trained personnel, equipment, processes and other supplies.

This naivety might be touching in someone who is still growing into such a role as his. But given the extent to which he and his Foundation skew global health, development and spending priorities, treating his word as gospel is downright foolish.

The fact is, Mr Gates, most deaths among HIV positive people in developing countries are preventable and treatable. Most of the people who are dying should not be dying. They die because developing country health services can barely even dole out the antiretroviral drugs they are given in such huge quantities (sometimes), while they don't have the cheap drugs they need to stop people from dying from diseases the Gates Foundation doesn't consider worth bothering about.

But Gates still reverts to his obsession, drugs, in the form of vaginal microbicides and PrEP. We've tried forcing drugs down the throats of HIV positive people, lets now try to force them down the throats of HIV negative people as well. Oh, and he wants a vaccine as well. And male circumcision.

Money is not going into investigating how people are becoming infected with HIV. It's assumed that sex is the problem and drugs are the solution. Health systems just don't seem sexy enough to merit attention, nor do improved infrastructures, water and sanitation, basic education or anything else that might alleviate the conditions that allow HIV to spread rapidly.

Gates said "given all the lives that are at stake, I am willing to be viewed as a troublemaker by people who are happy with the status quo". Sorry, Mr Gates, but you are the status quo in development, Indeed, that's what makes you a troublemaker.

The Health of the Poor: a Valuable Commodity for Big Pharma

Roger Tatoud wonders out loud about medicalisation of sex in OpenDemocracy but I would be more worried about medicalisation of health. PrEP operates by putting HIV negative people on antiretroviral (ARV) drugs in the hope that this will reduce their susceptibility to the virus. And 'treatment as prevention' advocates claim that putting HIV positive people on ARVs will ensure that they are less likely to transmit the virus to HIV negative people.

Both processes are part of what some claim is a new paradigm. However, treatment is not prevention. It may play a part in prevention programs but it is not thereby a prevention paradigm. And PrEP is of little use without other prevention measures, such as condom use. In fact, condom use on its own is probably just as effective as condom use in conjunction with PrEP.

I've only managed to see the first page of an article by Vinh-Kim Nguyen and others, entitled 'Remedicalising an epidemic: from HIV treatment as prevention to treatment is prevention'. But they seem to be arguing something along similar lines.

Prevention has long been underfunded and transmission rates are not declining in many countries outside of Africa. As for the African countries with declining transmission rates, it is not really clear why they are declining. Declines in incidence started long before most prevention programs came into existence. This was also long before significant rollout of ARVs.

But a few tens of millions of HIV positive people is not a big enough market for the pharmaceutical industry, they have to put tens, or even hundreds, of millions of people on drugs even though they are not sick.

A Technical 'Solution' in Search of a Problem

In an article on self-testing for HIV in aidsmap.com:

"Dr Renee Ridzon of the Bill and Melinda Gates Foundation warns that self-testing is going to be necessary if antiretroviral-based prevention methods such as microbicides and pre-exposure prophylaxis become available, simply to accommodate the volume of regular testing that will be necessary to use these methods safely."

No surprise that the Foundation would be involved in anything to do with medicalization of health and the use of technical solutions in the absence of adequate health facilities, health personnel and even more general health (as opposed to disease) issues such as water and sanitation, air quality, living conditions, etc.

This sounds very much like a solution in search of a problem, a phenomenon that makes up a very significant proportion of Big Pharma sponsored health 'research' (the Foundation being an integral part of Big Pharma).

I've discussed this in more detail on my HIV in Kenya blog.

Why do Microbicide Trials Make No Effort to Establish Mode of Transmission?

In contrast to the CAPRISA vaginal microbicide trial, which received copious amounts of coverage, not so much is said about the PRO2000 gel trial. The latter trial was deemed safe but it did not prevent transmission of HIV to women.

As is customary in these trials, no attempt was made to establish how HIV was transmitted. It was just assumed that it was sexually transmitted and male partners were not tested.

Incidence was high, between 3.9 and 4.7 per 100 woman years, despite condom use being high. Condom manufacturers might even be a little bit curious as to why people who were not engaging in sex very much, were avoiding unsafe sex and had been selected because they were HIV negative, seemed to be so susceptible to HIV infection. They were even screened for other sexually transmitted infections (gonorrhea and chamydia).

The ostensible aim of microbicide trials will not have been achieved. In order to prevent HIV transmission it needs to be clear how the virus is being transmitted. Microbicides may have some influence on non-sexual HIV transmission but people are unlikely to use them to prevent infection when they are not having sex unless they are made aware of the existence of such risks.

And even then, people will not be choosing to use vaginal microbicides. They would not be the first choice if you were a man, going for an operation, visiting the hairdresser, injecting drugs, pregnant or about to give birth, getting a tattoo, etc.

The failure to establish mode of transmission is not just a flaw. Non-sexual modes of transmission may turn out to be responsible for a significant number of HIV infections in some epidemics, such as those in high-prevalence sub-Saharan African countries.

If so, vaginal gels may achieve little more than continuing to deflect attention from the abysmal health services that are undoubtedly infecting African patients with all manner of diseases, not just HIV.

Dear CAPRISA 004, You've Been Dumped

The most hyped issue by far at the hype-laden Vienna Aids Conference a few months ago was the CAPRISA 004 microbicide trials, which is said to be "at least 39% effective in preventing HIV infection" when applied before and after sex. There were calls for the technology to be made widely available as soon as possible, though the trial results are not impressive and several more years, at a minimum, are required before a viable product results.

On the strength of the hype, attempts were made to raise $100 million to carry out further trials. But only $58 million has been raised so far. What has happened to all the enthusiasm of a few months ago? Given his endorsement of technological fixes, especially pharmaceutical ones, why hasn't Gates coughed up the shortfall yet? And why is so much of the money coming from donors? Big Pharma constantly bleats about how much money they invest in products as an excuse for extorting enormous profits out of what is often publicly funded research. Where are they now?

Many African countries are finding just how quickly donors pull out when it suits them, although these countries were heroes in the fight against HIV only a short time ago. Far fewer people receive antiretroviral drugs than need them, many of them are lost to follow up, develop resistance, die of something curable or simply cease to be important now that HIV treatment on its own is no longer flavor of the month.

What could explain this sudden lack of interest? Will PrEP experience similar fluctuations?