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.

Science Awards: Virtuous Circle or Spooky Cabal?

There are few things that make me think 'collusion of interested parties' than prominent awards, with the exception of peer reviewers, who always me think of Freemasons for some reason. For all I know, though, they could all be completely innocent and/or unrelated.

Anyhow, Science Magazine has awarded two of their ten prizes to the highly controversial and unconvincing Tenofovir vaginal gel (the CAPRISA 004 trial) and the almost equally unconvincing pre-exposure prophylaxis drug (the iPrEx trial). There is a lot of USAID and PEPFAR funding behind both of these, so the poor trial results may not matter too much.

The ongoing concentration on capital hungry technologies and technical expertise tends to mask one of the biggest problems that poor countries face: shortage of skilled health personnel. Here in Tanzania there is one doctor for approximately every 50,000 people (compared to about one for every 170 people in Cuba). What are people going to do with all these drugs and other technologies, assuming they can ever afford them?

This problem, like many of the other real problems developing countries face, is ignored by the cabals of industrialists, megaphilanthropists, technologists, politicians, religious fanatics and other jackals of the HIV industry. But it is not going to just go away.

Of course, it's of little interest to the same interested parties, who wish to establish markets, not undercut the very source of their current and future wealth. In addition, HIV related technologies need to be put through rigorous trials in countries with high HIV prevalence to prove their worth. So even if 'aid' money will not be diverted to subsidize these markets, contacts with developing countries need to be maintained. After all, that's what 'aid' is, a tool of foreign policy.

Botswana has announced that it is going to concentrate on prevention, and not before time. The country has one of the worst epidemics in the world. But perhaps now they will reject the self-serving arguments about treatment 'being' prevention and about HIV funding 'strengthening health systems' or about it  not diverting funding from other health issues. If only other high prevalence countries, and even low and medium prevalence countries, would follow suit and stand up to the moneyed interests.

Botswana simply can't afford antiretroviral drugs at current levels of usage, never mind the annual increases in incidence adding to the costs, along with resistance and other factors ensuring that costs will rise exponentially, not linearly, in the future. All high prevalence countries with large numbers of people on antiretroviral drugs are experiencing the same problems as Botswana.

But Botswana also seems to have realized that much of the money spent on behavioral interventions has been wasted. Perhaps they'll take another step and realize that this failure of behavioral interventions may be because HIV transmission is not all about sexual transmission?

Using mere technologies to solve deeply rooted development problems is as likely to work as planting seeds on the moon (in its present state). And if I thought the HIV industry really wanted to solve development problems, health and HIV related problems in particular, I would think they are behaving like fools.

But I don't think anyone seriously believes such naive claptrap. They are business people, involved in protecting their markets and ensuring that they make as much money as possible, regardless of the consequences for people in developing countries.

Will People Use Condoms With Pre-Exposure Prophylaxis or Microbicides?

A trial of combined condom and diaphragm use found that, although condom use increased during the trial, it returned to pre-trial rates afterwards. A commentator notes "What happens after trials has always remained very much a mystery". This appears to be true, and it's very disturbing.

Trial conditions are very different from non-trial conditions. Strict protocols are observed, at least in theory, so one would expect behavior to be substantially different once the intervention in question moves into the field. Especially when the trials show that the intervention only produced a small or temporary change in behavior. But results may even be a mere artefact.

Results of trials of mass male circumcision, microbicides (such as the tenofovir based gel tested in the CAPRISA trial), pre-exposure prophylaxis, test and treat strategies and other approaches to HIV prevention, which depend on the possibility of influencing sexual behavior, all share the risk of being artefacts.

Ariane van der Straten was involved in the Methods for Improving Reproductive Health in Africa project. This showed that, in many areas, the interventions involving diaphragms and lubricant, in addition to condoms and counselling employed for the control group, resulted in slightly higher rates of HIV transmission. However, the differences were not statistically significant.

Van der Straten points out that "it is a challenge to use concurrent HIV prevention methods, particularly barrier methods". All the technical solutions mentioned above require people to continue using condoms, even after circumcision and/or using microbicides or taking pre-exposure prophylaxis. Does she mean 'it is a challenge' or 'it is probably inadvisable'?

The study emphasised an unmet need for birth control, but this is hardly a surprise.

Van der Straten's concluding remark is particularly related to one of the assumptions about microbicides, though it may apply equally to pre-exposure prophylaxis. That is the claim that they are 'female-controlled'. Van der Straten says "In the past we have been naive, thinking that female-controlled methods could be used independent of men's involvement, but it's difficult to use any of these methods secretly, so there is a need to involve male partners in female-controlled methods so that they support their partners".

The full report is also freely available online.

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.

Millions of Pills Haven't Worked So Let's Try Billions of Pills

The 'treatment as prevention' approach to reducing HIV transmission is getting airtime again, this time because the pioneer of the strategy has receive the Einstein award. Treatment as prevention is more of a hypothesis than a strategy or approach, really. But given the rarity of feasible HIV prevention strategies the HIV industry needs something to obsess about.

The hypothesis suggests that, because successful HIV treatment reduces the viral load to the extent that HIV positive people are very unlikely to transmit the virus, prevention programs could rely on this to significantly cut HIV transmission.

The number one flaw in the hypothesis is that it assumes that most HIV is transmitted sexually. This is a rash assumption in countries where health service provision is of extremely low quality. But the HIV industry has little interest in health or health service provision when they can sell lots of drugs. And it's a media friendly issue, with its combination of technical fix and the implication of illicit sex.

Of course, rolling out treatment to as many HIV positive people as possible when they need them is a good thing. But it may not have much impact on transmission rates. And ensuring that they didn't become infected in the first place would be preferable. It is hardly reassuring to those who are currently HIV negative that so little is going to be done to help them stay that way.

Another flaw is the assumption that a disease can be eradicated by some technical fix when the circumstances under which the disease became an epidemic are left pretty much as they are. So there is no need to improve health, education, infrastructure or social services? But these questions are not popular in the industry.

HIV testing has been around for some time now, in developed and developing countries. Most people never get tested, others test once and never again. But treatment as prevention requires the majority of people, or as near to 80% of people as possible, to be tested regularly, perhaps once a year.

It remains to be seen how many developing countries will be able to encourage such huge numbers of people to turn up for testing every year, or even how such programs will be administrated in countries where health services are so poor. High prevalence countries currently have a lot of trouble accounting for the HIV positive people they know about, a fraction of the total infected.

The above article on the award raises the issue of 'risk compensation', where it was feared that the availability of HIV treatment that also reduced infectiousness might result in increased risky sexual behavior. But where sexual behavior is not the main driver of HIV transmission, this is something of a red herring.

It's great to hear that treatment as prevention works so well in British Columbia. But I don't think the health problems in BC are anything like the health problems in East Africa. And I'm pretty sure the health systems (also education, social services, infrastructure) in BC are not like those in East Africa.

In short, the technology on its own is not the solution to an epidemic that has many determinants. This technical fix may have some impact in isolated pockets of East Africa, especially in randomized controlled trials, but people need a lot more than just pills to stay healthy. Far from obviating the need for decent health services now that some great technology is available, that technology requires adequate health services, and probably education, infrastructure and social services.

Are Healthy People More Likely to Take Drugs than Unhealthy People?

Loss to follow up is a common problem with HIV treatment programs and up to 40% of East Africans may cease to collect their drugs at some time. They may have gone somewhere else or died, but it's hard to tell. Records are not always well kept.

It's hard to know how good people will be at taking drugs to prevent HIV, as opposed to those that treat HIV. Early papers on adherence seemed keen to report good news, that people in developing countries were even likely to be better at keeping to treatment regimes than people in rich countries. But later papers have not always been so optimistic.

I have seen several mentions recently of people preferring to pray and believe that God will save them, keep them alive, 'cure' them of HIV, etc. People who believe this don't always stop their treatment, although some do. But even temporary lapses in taking antiretroviral drugs can cause problems such as opportunistic illnesses and resistance build up.

I have even come across people who have insisted that praying is the best response because God will decide, whatever the outcome is. This is disturbing to witness, especially when one suspects that many people taking this view also seem to associate HIV with some kind of evil or sin.

A recent article suggests that some young people in Uganda are being persuaded to give up taking Aids drugs and relying on their beliefs instead. Some of those persuading them are possibly not even genuine pastors, though it seems equally inexcusible whether they are genuine or not.

Proponents of PrEP tend to ignore the potential problems of ensuring that people who are not sick take drugs as required in order to prevent infection with HIV. Especially as research into exactly how most HIV is transmitted in high prevalence countries is thin on the ground.

Never Mind Efficacy, Think of the Profits

There's an interesting article in the Emerging Health Threats Forum about bird flu behavior change campaigns and people's perception of risk. It was found that "People who witness avian flu outbreaks in animals near them fear the disease less than those with no experience of it".

Most HIV prevention campaigns have attempted to influence people's sexual behavior by warning them about certain risks and telling them how to avoid them. Some of these campaigns have been assessed and the results tend to show that many people continue with the behaviors considered to be risky.

Speculation has suggested that HIV transmission rates in Uganda, and eventually in some other countries, started to decline once people realized that many of those around them were becoming sick and dying. This is unlikely to be true because high death rates would have occurred some years after declines in transmission started.

However, much HIV prevention work continues with the assumption that people will modify risky behavior once they know that it is risky and what steps they can take to ensure that they don't become infected. And perhaps the assumption is, to some extent useful. Perhaps people will eventually begin to take precautions and the bulk of sexual transmission of HIV will be eradicated.

Wide availability of PrEP in high HIV prevalence countries may become a 'protective' behavior, something people who cannot avoid sexual risks can take to reduce the risk of infection. In textbook cases, where HIV transmission really does occur because people are taking unnecessary and avoidable sexual risks, PrEP may even have a substantial effect on sexual transmission.

Unfortunately, a good deal of sexual transmission is probably not of the textbook variety. The incredibly high rates of risky sexual behavior attributed to Africans in the textbooks are more likely to be a widely shared fantasy, stubbornly held by those who are in the best position to see how such views are completely without foundation.

But even where PrEP is available to prevent some sexual HIV transmission, it is unlikely to have any impact on non-sexual HIV transmission. The fact that UNAIDS and other institutions are not even targeting non-sexual transmission doesn't help, but giving out pills, to however many people, is not the most expeditious means of reducing, for example, health care related exposure to HIV.

It is not a new discovery that behavior and behavior change are complicated and difficult to effect. And this is not to say that some kinds of behavior change shouldn't be attempted and facilitated. However, concentrating all our attention on sexual HIV transmission, without even attempting to find out how much of the virus is spread though non-sexual modes, results in an unknown level of avoidable infection.

PrEP may hold some promise for certain kinds of sexually transmitted HIV but it will not eradicate the virus. And it will have little or no impact on non-sexual transmission, which is probably responsible for a large proportion of the highest prevalence epidemics, all of which are found in a handful of sub-Saharan African countries.

Some advocates of PrEP may truly believe that it could eventually play a part, perhaps a big part, in eradicating the virus. People who believe this don't know very much about HIV. But I suspect that PrEP is just a clever way of increasing HIV drug sales by several hundred percent, perhaps even several thousand percent.

Having a ready supply of trial participants in countries where the virus is common will help a lot in getting the drugs on the market. Meanwhile, epidemics in African countries continue on trajectories that are completely independent of any HIV prevention programs that have taken place so far.

Gates Foundation Spends Billions on Potemkin Villages

Bill and Melinda Gates seem to think people have a downer on development aid, if their recent attempts to present us with 'success stories' is anything to go by. One of problems with Gates and Co is that they have a lot of say in how the development agenda is set because they have the money to blow on whatever they feel like. So if they feel like blowing their money on puffing their own projects and interests, they'll do it. And if they feel like hyping PrEP, genetically modified organisms and numerous other purely technical quick fixes, they'll do that.

In recent years, questions have been raised about the way things have been done in development up to now. Perhaps that was going nowhere and things will just continue to benefit the donors more than people living in developing countries. But what the Gates Foundation is doing tends to obscure what is going on, to paint a colorful picture when what we need is an accurate picture. Worse still, because they get to set the agenda, issues that have been ignored in the past will stay in the dark and issues that these over paid bureaucrats like will be even more hyped than before.

Nothing I read about Gates and his cronies makes me think that he understands poverty or any other issue in development. I don't even think he cares very much about such things. I have no idea what motivates him but I don't see him engaging with anything but opportunities to force unneeded and possibly harmful technologies on people who are too disempowered to object. The foundation's work risks undermining other work that is going on in development and unless they can learn to cooperate and even take their lead from people who know what they are doing, who know what they are talking about, development will be stifled.

For example, PrEP is not going to reduce the risks that HIV negative people face to any great extent. People who face sexual risks can take other measures and if they can't, it's hard to see how some pills with help. For those who face non-sexual risks, the pills may work, but their availability is not a reason for allowing unsafe medical and other practices to continue. PrEP is in danger of sweeping the real problems under the carpet, but without reducing the risks appreciably.

Genetically modified organisms and other technical quick fixes are similarly distracting from the real issues that give rise to poverty, food insecurity, contaminated water and poor sanitation, inequalities of various kinds and any other development problems. Technical solutions are in the hands of technocrats like Gates and they will always remain in the hands of the rich and powerful. People don't die for want of pills for, say, cholera, they die for want of fresh water. Cure cholera and a handful of other water borne diseases and people will die of something else, probably also water borne.

The majority world is not a sand-pit for Gates and recipients of his largesse to play in, it is reality for most of the world's population. Big 'philanthropy' needs to be answerable to the public before it does irreparable damage, if it hasn't done so already.

HIV Still Holds Good Opportunities for Investors

A worrying aspect of the ever increasing medicalization of health, including HIV/AIDS and other diseases that are especially common in developing countries, is the question of how the commodities involved will be paid for. Many people advocating the greater use of drugs, perhaps most, have an interest of some kind, financial, political, career related, perhaps all of these.

But the fact is, people in developing countries can not pay for expensive commodities. And there's no reason why they should do so when their most urgent needs are not commodities, they are basic human rights, such as food, water and sanitation, basic health services, education, infrastructure and other social services. People don't generally die for want of expensive medication, though they often die for want of very cheap medication, medication which is too cheap for Big Pharma to be interested in.

Protesters in India have been arrested for arguing that the European Union (EU) is threatening the production and use of cheap generic drugs by hoodwinking India into signing a 'Free' Trade Agreement (FTA), which will 'allow' India to export some of its products in greater quantities to Europe, but at derisory prices. In reality, the agreement is so that European countries can export their overpriced goods, often goods that are only likely to benefit wealthier Indians, to a country that has no need of these goods.

Medicins Sans Frontieres is running a campaign to prevent the EU from abusing its power in this way (email the EU trade commissioner to protest!). The FTA would apply to all drugs, whether intended for primary health or otherwise, whether lifesaving or not. It would also apply to all other goods and the conditions go beyond what is required by the World Trade Organization's Trade Related Aspects of Intellectual Property Rights agreement (TRIPS). Those who naively support the greater use of PrEP could take a little time to consider if such a strategy would really benefit people who are most at risk of HIV infection.

Beware of What We Don't Know About PrEP

It might be thought that if HIV were one day, not just preventable, but also curable, that prevalence in most countries would go down very quickly and anyone infected in the future would be cured, sooner or later.

But are all preventable diseases prevented, where possible? And are all curable diseases cured? Cholera, malaria, polio and a huge range of other diseases can all be prevented by provision of clean water and good sanitation and most of them are curable (although clean water is also required for this, not just drugs). Yet water-borne diseases are endemic in many countries and kill vast numbers of people. And polio, despite considerable efforts, some successful, just keeps coming back, to a large extent because people keep drinking water contaminated with sewage.

So why should pre-exposure prophylaxis (PrEP) for HIV be any different? Perhaps HIV is seen as politically important. Well, it certainly is politicized. But then, a massive cholera outbreak in Zimbabwe last year was also politicized. It received a lot of attention, one suspects, because Zimbabwe and Mugabe were receiving a lot of attention.

Cholera outbreaks are a reflection of very poor water and sanitation provision. The failure to deal with such an outbreak efficiently reflects badly on the strength of the country's administration and on the strength of their health services.

However, the cholera epidemic ceased to interest the world's media, perhaps because it eventually petered out, as epidemics sometimes do. Water and sanitation provision are unlikely to have been improved much, the same probably applies to health services. As for the administration, all that can be said is that the medial has gone off to ogle at something else.

How long will it take the world's media to focus on the current cholera outbreak in Nigeria? Perhaps the political situation is not considered interesting enough at the moment, but as a health story, it doesn't seem to have got around yet. Ok, the story is getting around now, but mostly among the African and NGO press. It has even appeared, briefly, in the mainstream media, but it has not been very widely covered, given the implications of such an epidemic.

When the media does get around to covering the outbreak, it will probably concentrate on the sheer magnitude, rather than the conditions that allowed the outbreak to become an epidemic. The media may even reflect on the irony of such an epidemic occurring when it's so easily predicted and prevented.

We know the conditions under which cholera outbreaks become epidemics, the determinants of such large scale health emergencies. We know how to substantially reduce the probability of such an outbreak and how to prevent it from escalating. You will find the perfect conditions for outbreaks of cholera and other water-borne diseases in most countries in Africa, right now.

'Emergencies' are not always unforeseen events. We might not know when and where they will occur but we always know the sort of places where they might occur, the conditions under which they will occur, given time. We usually have (or could easily obtain) a good idea of how many people are vulnerable to injury and death if they do occur and how to improve the conditions to the extent that an outbreak can be contained and people treated until their health is restored.

People needn't suffer from and die from many of the preventable and curable diseases that they do suffer and die from. But we also have the capability to provide HIV positive people with palliative care so they don't have to suffer unnecessarily, yet many don't receive such care. Many people who need antiretroviral drugs (ARV) either don't receive them or fail to keep on taking the drugs. In other words, many people suffer from and die from Aids, unnecessarily.

Even if HIV PrEP were a reality, and it is far from that, why should we believe that the practicalities of distributing such drugs to the people who need them, when they need them, for as long as they need them, will ever be part of the intention of those who keep screaming about how important PrEP is? Being able to do something is not the same as doing it, or having any intention of doing it.

If PrEP advocates would be a little honest and balanced in their arguments, I might give them some credence. But it is the very absoluteness of their pronouncements, the purity of their stated intentions, the apparent goodness and even the applicability of PrEP to the world that makes me think that the whole thing is part of a broader aim to vastly increase sales of relatively useless pharmaceutical products to people; any people at all.

One of the most worrying aspects of PrEP and HIV is that, unlike water-borne diseases, we don't know why such huge numbers of Africans become infected with HIV. We know that people who are members of some demographic groups in some countries are more likely to be infected than people from other demographic groups and countries. But we are not certain, despite assurances to the contrary, why this is so.

Everyone drinks water and most people have sex. Only some people drink contaminated water and only some are likely to have sex with a person who is HIV positive. But in most demographic groups in most countries, the likelihood of becoming infected with HIV, despite having regular, unprotected sex with someone who is HIV positive, is very low. Until we understand why this is so, PrEP will be of little use, if any, in high HIV prevalence countries.

The Opposition is Real, it's the Defense that is Fabricated

In an article entitled "The Abandoned Trials of Pre-Exposure Prophylaxis for HIV: What Went Wrong?", Singh and Mills make the very assumption about PrEP that they are not in a position to make: that it may be useful for women involved in commercial sex work. As is clear from a number of studies, high prevalence of HIV is not very closely related to sexual behavior nor to 'high risk' groups, such as commercial sex workers.

Therefore, we are still in the dark about how PrEP should be used. Making PrEP available to low risk groups would be ridiculous, but I think that is what the pharmaceutical companies involved would like; to put lots of healthy people on drugs that they need to take in large quantities for much of their adult life.

The authors of the paper try to use seemingly reasonable arguments and suggest that the industry needs to be 'proactive' in its dealings with those who oppose the creation of markets for useless pharmaceutical products, taking advantage of cheap research subjects in developing countries. But by 'proactive', they seem to be recommending that the industry get in quickly and preempt any potential opposition.

They talk approvingly and rather naively about the involvement of the Bill and Melinda Gates Foundation in getting both sides together, as if the foundation is anything other than a major part of the HIV industry that stands to profit handsomely from its investments in Big Pharma.

Differences between activists and the HIV industry are not mere 'ideology'. Activists are not convinced that PrEP has anything to offer anyone but the pharmaceutical industry. Yes, the goal is combating Aids and the target is people who are HIV positive (and those who are at risk of becoming infected). But PrEP is irrelevant to both of those. So activists will continue to oppose it.

Drugs for the Healthy, Drugs for the Sick, Drugs for those In Between

Joep M A Lange expresses his frustration about protesters 'derailing' trials of PrEP a few years ago, referring to the halting of the trials in Cambodia, Cameroon and Nigeria. He wishes that protesters would all operate under some kind of umbrella, presumably so they can all be bought off all at once, like himself. But there is a good reason why protesters do not operate under an umbrella organization: they often have very different agenda.

And there are many reasons for questioning the use of PrEP as an ostensible means of reducing HIV transmission in developing countries. Some would argue that health is not purely a matter of disease eradication and they object to the medicalization of health, where people dying of water borne diseases are given drugs which they swallow using contaminated water.

Others might worry about the side effects of taking drugs, especially for healthy people. Then there's resistance, where people taking PrEP might be or become infected with HIV and resistance would develop. They would have a difficult and expensive to treat strain of HIV, which they could easily transmit to others. The 'cure' would have made things a lot worse.

These are all legitimate worries and they all need to be on the drug companies' agenda, whether they like it or not. They can't be relegated to any other business, crowded under an 'umbrella', to be treated with the same contempt that the pharmaceutical industry treats people in high HIV prevalence countries, HIV positive and HIV negative alike.

But there are two other worries I'd like to highlight here: firstly, Joep raises the issue of 'female-controlled' prevention techniques (though he says technologies because it musth be high tech, right?). The drug industry likes to point out how terrible the plight of women and children is and how men are so unreliable and badly behaved and that they are making PrEP available to help the most vulnerable people in high HIV prevalence countries.

But this is an argument for researching the issue of disempowerment and ways of alleviating it. Of course, drug companies may not have a big part to play, you certainly can't cure those problems with a drug. But I suspect that's how they want to push their products. They should consider how decades of availability of contraceptive drugs haven't done anything for the disempowered, nor much for fertility, either.

A second important issue around PrEP is that the HIV industry as a whole, that vast 'umbrella' of people and institutions who are doing very well out of the HIV pandemic and want to do a whole lot better, doesn't know a great deal about how HIV is transmitted. Or rather, much of their 'technology' is aimed at sexual transmission of HIV when non-sexual transmission of HIV is not talked about.

Joep and the string of competing interests he lists in his article have been trying to set the agenda for years, they are still trying. Opposition should come from anywhere there is a legitimate worry about the agenda for every international HIV/Aids conference, because the worries are many. Whereas the agenda of Big Pharma is always the same: how to get bigger.

Healthy people don't need medicine and sick people don't need useless, potentially harmful medicine. As long as there is Big Pharma, stupid ideas like PrEP and hyenas like Joep, I hope there will also be protests and protesters, shouting all the louder because they don't have access to the high platforms and the influential ears enjoyed by the HIV industry.

Welcome to Pre-Exposure Prophylaxis or PrEP

Preventing a disease may seem preferable to waiting until someone becomes infected and then treating them. But HIV pre-exposure prophylaxis (PrEP) is a bit different. In countries with high HIV prevalence, such as Swaziland, Lesotho, South Africa, Botswana, Zimbabwe and a number of others, so many people are at risk of being infected, the cost of providing medication for them all would be prohibitive. After all, PrEP is not a once off inoculation; it is something you need to take for as long as you are sexually active.

So why write a blog about that? Well, I have searched the web a good deal for information about PrEP and it is overwhelmingly positive and overwhelmingly shaped by the very people who stand to gain from promoting it, namely the pharmaceutical industries, Big Pharma. I would expect to find at least some articles that criticize or question or even try to analyze PrEP. But I only came across one. So I'll be on the lookout for others.

HIV is a virus spread by contaminated bodily fluids, such as blood, semen, vaginal fluid and others. It is relatively difficult to spread through sexual contact, especially penile-vaginal contact, though anal sex is especially dangerous. But some of the most common routes of infection could be non-sexual. In which case, it would be a waste of effort and money to target people on the basis of their assumed sexual behavior with PrEP. Unless you wanted to waste money; unless it isn't your money; unless it is development money.

If you want to hear cheers for PrEP, just have a look at the Aids Vaccine Advocacy Coalition (AVAC), a pharmaceutical poodle that yaps a lot but, ultimately, protects nothing but Big Pharma profits. It claims not to be supported by Big Pharma, but they do get money and support from institutions that cheer for little else: UNAIDS, CDC and IAVI. And then there's the Bill Gates Foundation, which makes a lot of money from Big Pharma and other, equally admirable, multinational interests.

I have written about PrEP elsewhere, especially on my HIV in Kenya blog (just search for 'PrEP' in the search box) and briefly in the blog, Kwa Sababu, now sadly defunct. But I think the field of PrEP is in serious need of analysis and discussion. I hope others feel the same way.