by Charles
A few weeks ago, Michael Fumento asked why HIV is so prevalent in Africa, and it got me to thinking about our approach there. No small part of the problem is the quality of information that comes to us, but there are also more steps that can be taken. While the ABC approach is a sensible one for dampening the spread of AIDS in Africa, it seems like a few more letters should be added to the alphabet soup. Here are mine:
- Diagnosis. How can we solve the problem if we don’t know the scope? As this article attests, estimates of those infected with HIV have been wildly overinflated. Estimates are based more on computer science than medical science.
- Eradicate infected needles and body piercings.
- The ABC approach should stay in effect. Abstinence is a foolproof way to prevent sexually transmitted HIV. If folks cannot abstain, then the next best route is to be faithful. If that cannot be done, then men should strap on condoms. Another "C" should be added: ‘Cides (that would be microbicides).
- If condoms are refused, then the next best thing is to eschew recipient anal intercourse, which is by far the most efficient way to get sexually infected with HIV.
- Try freedom. Africa remains a dark continent in terms of political rights and civil liberties. Out of forty-seven countries on the continent, only eight are free. There is a direct correlation. The most prosperous countries–which also happen to have the best medical care–happen to be the freest.
- Other avenues and alternatives. Malaria and tuberculosis cause many more deaths. Also, as this Economist article describes, there is a now a proven path for developing new drugs specifically for the third world. The practical effect will be more net lives saved.
The acronym, DEABCETA, is long, unwieldy and does not roll off the tongue, but it strikes me as a better plan. For those whose first response to eschew is "gesundheit", stop right here. For the rest…
Diagnosis
One of the more frustrating problems with HIV in Africa is the lack of reliable numbers. Unlike the CDC, which documents actual confirmed cases, HIV statistics in Africa are reliant on computer models and statistical projections. South African journalist Rian Malan has been in the forefront of questioning estimates made by various health organizations, particularly WHO and UNAIDS. By 2000, these organizations were estimating 17 million deaths in Africa, with AIDS as the culprit, and 29.4 million presently infected. The problem is that these estimates were horribly over-exaggerated.
People are dying, but this doesn’t spare us from the fact that AIDS in Africa is indeed something of a computer game. When you read that 29.4 million Africans are ‘living with HIV/AIDS’, it doesn’t mean that millions of living people have been tested. It means that modellers assume that 29.4 million Africans are linked via enormously complicated mathematical and sexual networks to one of those women who tested HIV positive in those annual pregnancy-clinic surveys.
Modellers are the first to admit that this exercise is subject to uncertainties and large margins of error. Larger than expected, in some cases.
A year or so back, modellers produced estimates that portrayed South African universities as crucibles of rampant HIV infection, with one in four undergraduates doomed to die within ten years. Prevalence shifted according to racial composition and region, with Kwazulu-Natal institutions worst affected and Rand Afrikaans University (still 70 per cent white) coming in at 9.5 per cent. Real-life tests on a random sample of 1,188 RAU students rendered a startlingly different conclusion: on-campus prevalence was 1.1 per cent, barely a ninth of the modelled figure. ‘Doubt is cast on present estimates,’ said the RAU report, ‘and further research is strongly advocated.’
A similar anomaly emerged when South Africa’s major banks ran HIV tests on 29,000 staff earlier this year. A modelling exercise put HIV prevalence as high as 12 per cent; real-life tests produced a figure closer to 3 per cent. Elsewhere, actuaries are scratching their heads over a puzzling lack of interest in programs set up by medical-insurance companies to handle an anticipated flood of middle-class HIV cases. Old Mutual, the insurance giant, estimates that as many as 570,000 people are eligible, but only 22,500 have thus far signed up.
In Grahamstown, district surgeon Dr Stuart Dyer is contemplating an equally perplexing dearth of HIV cases in the local jail. ‘Sexually transmitted diseases are common in the prison where I work,’ he wrote to Lancet, ‘and all prisoners who have any such disease are tested for HIV. Prisoners with any other illnesses that do not resolve rapidly (within one to two weeks) are also tested for HIV. As a result, a large number of HIV tests are done every week. This prison, which holds 550 inmates and is always full or overfull, has an HIV infection rate of 2 to 4 per cent and has had only two deaths from AIDS in the seven years I have been working there.’ Dyer goes on to express a dim view of statistics that give the impression that ‘the whole of South Africa will be depopulated within 24 months’, and concludes by stating, ‘HIV infection in SA prisons is currently 2.3 per cent.’ According to the newspapers, it should be closer to 60 per cent.
On the face of it, these developments suggest that miracles are happening in South Africa, unreported by anyone save a brave little magazine called Noseweek. If the anomalies described above are typical, computer models are seriously overstating HIV prevalence. A similar picture emerges on the national level, where our estimated annual AIDS death toll has halved since we eased UNAIDS out of the picture, with further reductions likely when the new MRC model appears. Could the same thing be happening in the rest of Africa?
Most estimates for countries north of the Limpopo are issued by UNAIDS, using methods similar to those discredited here in South Africa. According to Paul Bennell, a health-policy analyst associated with Sussex University’s Institute for Development Studies, there is an ‘extraordinary’ lack of evidence from other sources. ‘Most countries do not even collect data on deaths,’ he writes. ‘There is virtually no population-based survey data in most high-prevalence countries.’
Bennell was able, however, to gather information about Africa’s schoolteachers, usually described as a high-risk HIV group on account of their steady income, which enables them to drink and party more than others. Last year the World Bank claimed that AIDS was killing Africa’s teachers ‘faster than they can be replaced’. The BBC reported that ‘one in seven’ Malawian teachers would die in 2002 alone.
Bennell looked at the available evidence and found actual teacher mortality to be ‘much lower than expected’. In Malawi, for instance, the all-causes death rate among schoolteachers was under 3 per cent, not over 14 per cent. In Botswana, it was about three times lower than computer-generated estimates. In Zimbabwe, it was four times lower. Bennell believes that AIDS continues to present a serious threat to educators, but concludes that ‘overall impact will not be as catastrophic as suggested’. What’s more, teacher deaths appear to be declining in six of the eight countries he has studied closely. ‘This is quite unexpected,’ he remarks, ‘and suggests that, in terms of teacher deaths, the worst may be over.’
The Guardian has more on Malan and his journey through the jungle of AIDS statistics. By wildly overstating these HIV/AIDS fears, organizations with vested interests get more money, sadly diverting funds from malaria (350 million afflicted per year) and tuberculosis (two million afflicted per year), both of which are eminently more treatable at far less cost, saving more lives on par. Last September, the Kenya Demographic and Health Survey confirmed that the previous estimates were massively overinflated. The Telegraph:
Millions of Africans believed to have HIV/Aids are free of the disease, according to research published yesterday.
The survey will dismay those who claim the West is ignoring a pandemic so acute it could wipe out the populations of entire African states.
Scientists said the new report would force a rethink in the way the United Nations measures Aids prevalence on the continent.
The preliminary report of the Kenya Demographic and Health Survey suggested that HIV has infected about one million adults in the country. Previous estimates put the number at up to three million. Even so, these revised estimates are still based on representative sampling and computer modeling, not actual counts. What the article does not reconcile is how the estimates in Kenya were too high by 67% but only 25% too high across the continent. In either case, some of that $15 billion should be used for wide dissemination of reliable and fully sterilized testing kits.
Other statistics put forth by WHO and UNAIDS should also be scrutinized, particularly the claims that over 90% of HIV infections come from heterosexual contact. It raises the question: If the primary means of HIV transmission in the U.S. are receptive anal intercourse and intravenous drug use, why should it differ in Africa? In an AIDScience article:
The assertion that heterosexual transmission accounts for over 90% of HIV in African adults lacks supporting empirical evidence linking HIV to sexual behaviors. The evidence WHO/UNAIDS uses to buttress the heterosexual paradigm is mostly indirect and circumstantial, and much of it seems aimed at debunking the role of health care rather than substantiating the role of heterosexual contact. For example, the press release asserts, "children between 5 and 14 years, who are generally not sexually active yet, have very low infection rates." In fact, few surveys have screened for HIV in African children, and some (but not all) have reported substantial HIV prevalence. For example, 4.2% among urban children 6-15 years old in Rwanda in 1986 and 5.6% among 2-14 year old children in a national survey in South Africa in 2002. These rates, which are much higher than could be expected from vertical transmission, point to other means of transmission, possibly health care transmission. It should be noted that observed rates are not likely due to substandard tests (Rwandan cases were confirmed by Western blot, and tests used in South Africa have over 99% specificity) or to child sexual abuse or early sexual activity.
According to WHO/UNAIDS, HIV behaves like other sexually transmitted diseases (STD), and populations with high HIV prevalence (prostitutes, long-distance truck drivers, soldiers, and migrant workers) suggest sex as the principal risk. Such arguments are inferential, indirect and ignore conflicting epidemiologic observations. For example, in Zimbabwe during the 1990s, STD and HIV followed opposite epidemic trajectories.
Without attention to parenteral exposures, observations linking sexual activity to HIV infections are inconclusive. For example, sexually active populations, especially including prostitutes and their customers, are at risk for STD, which is commonly treated throughout Africa by injections in formal or informal health care settings. Recent estimates from WHO suggest that 17-50% or more of injections in Africa may reuse equipment without sterilization. As a consequence, the risk of HIV infection in STD clinics, where background HIV prevalence among patients is often high, may be considerable. Medical procedures during pregnancy, including drawing venous blood for syphilis tests, multiple tetanus vaccinations, and gamma globulin shots, add another set of potential health care risks. When health care is unsafe, HIV case distribution may reflect sexual activity circumstantially rather than causally. Studies that sort out this potential source of confounding are rare. Furthermore, there has been no consideration of the potential multiplier effect that may result from interaction between sexual and health care transmission in Africa.
The WHO/UNAIDS press release states, "there is no consistent association between higher HIV rates and lower injection safety standards." We are unaware of any studies that have systematically examined this correlation; we would welcome them. Specifically, we encourage studies to determine the frequency of health care exposures and level of infection control standards in different countries with generalized epidemics. This may require monitoring contamination of equipment ready for use, testing mothers of children with AIDS to see if any are HIV-negative, investigating clinics and hospitals suspected as the source of iatrogenic HIV infections, etc.
The press release claims that "modeling of the epidemic with the best available information also shows that the overwhelming majority of infections are due to unsafe sex. The accuracy of models depends crucially on their assumptions and on the quality of the data used to estimate parameters; indeed, models have often been used to justify orthodoxy by using estimates for key parameters that are at considerable odds with empiric evidence. For example, models purporting to describe heterosexual HIV transmission in Africa have supposed ulcerative STDs to amplify transmission risk by as much as 100 times.
Finally, the idea that penile-vaginal sex is driving HIV epidemics in Africa is a hypothesis that requires renewed scrutiny, not defensiveness. Studies seeking properly controlled empiric evidence need to be conducted to support or oppose this hypothesis. In our view, the published evidence suggests that: (a) two decades into the epidemic, such studies have yet to be done; (b) the heterosexual hypothesis is inadequate to explain fully the observed epidemic trajectories, especially in regions of intense transmission; and (c) irrespective of the precise proportions of HIV attributable to sexual activity or to unsafe health care, priority should be given to assuring safe health care in formal and informal medical settings world-wide, if only as a human rights issue.
Emphasis mine. Basically, groups like WHO and UNAIDS are irrationally scaring the world about the prevalence of AIDS in Africa, and they are distorting how the disease is getting transmitted. To a lesser degree, the Centers for Disease Control also provides a disservice with how it reports information. Given how it has reported on obesity, this should come as no surprise, but more on that further down the page.
Eradicate Infected Needles and Body Piercings
The BBC article was quick to dismiss the study, pulling a quote from a UNAIDS scientific advisor:
"We’re concerned that a report like this might tend to make people drop their guard and not use condoms, when it’s exactly using condoms that is required at this point."
The advisor was worried more about reductions in condom usage–clinging to UN conventional wisdom–than in the facts (which she did not dispute), and the facts from the study are compelling. A post from Medpunit:
A new study suggests that the African AIDS epidemic is from poor medical hygiene (i.e. reusing needles for injections) more than sexual promiscuity:
Research published by US experts indicates that the spread of HIV infections in Africa may be more closely linked to unsafe medical care than previously thought.
The report challenges widely held scientific views on the spread of the virus that can cause Aids.
It estimates that two-thirds of the people with HIV in Africa become infected mainly through contaminated needles rather than through sexual contact.
The UNAids organisation disputes the findings, and says there have not been adequate studies to support the conclusions that are drawn.
My very first thought when I read this was, “My God! Medical professionals reuse needles in Africa?” My second thought was, “Why would any organization object to the findings?” It’s much easier to provide clean needles than to change people’s sexual behavior.
Then, I read the study. It turns out that the crux of its argument is that before 1988, when the public health community adopted a consensus opinion that AIDS was transmitted in Africa mostly through heterosexual sex, there was plenty of statistical evidence that the HIV epidemic in Africa was caused by dirty medical needles. That evidence, according to the authors, was not only ignored, but suppressed by the world public health community:
First, it was in the interests of AIDS researchers in developed countries—where HIV seemed stubbornly confined to MSMs [homosexuals – ed], IDUs [IV drug users -ed], and their partners—to present AIDS in Africa as a heterosexual epidemic; ‘nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS’ … In a prominent 1988 article in Science, Piot and colleagues generalize with arguably more public relations savvy than evidence that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’. Second, there may have been an inclination to emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing programmes and efforts to curb Africa’s rapid population growth. Third, ‘the role of sexual promiscuity in the spread of AIDs in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans’, as Packard and Epstein document in a regrettably ignored 1991 article. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—eg, to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’ . In short, tangential, opportunistic, and irrational considerations may have contributed to ignoring and misinterpreting epidemiologic evidence.
That’s pretty strong stuff. The authors are charging that WHO and other public health groups ignored the evidence of an easy solution to stemming HIV spread because of their preconceived notions about Africans – that is, their prejudices.
Some of the highlights of the study:
HIV and STDs: According to the authors’ data, African HIV did not follow the pattern of sexually transmitted disease (STD). In Zimbabwe in the 1990s HIV increased by 12% a year, while overall STDs declined by 25% and condom use actually increased among high-risk groups.
Infection rate: HIV spread very fast in many countries in Africa. For the increase to have been all via heterosexual sex, the study claims, it would have to be as easy to get HIV from sex as from a blood transfusion. In fact, HIV is much more difficult than most STDs to transmit via penile-vaginal sex.
Risky sex? Several general behaviour surveys suggest that sexual activity in Africa is not much different from that in North America and Europe. In fact, places with the highest level of risky sexual behaviour, such as Yaounde in Cameroon, have low and stable rates of HIV infection. "Information…from the general population shows most HIV in sexually less active adults" .
Children and injections: Many studies report young children infected with HIV with mothers who are not infected. One study in Kinshasa kept track of the injections given to infants under two. In one study, nearly 40% of HIV+ infants had mothers who tested negative. These children averaged 44 injections in their lifetimes compared with only 23 for uninfected children.
Good access to medical care: Countries like Zimbabwe, with the best access to medical care, have the highest rates of HIV transmission. "High rates [of HIV] in South Africa have paralleled aggressive efforts to deliver health care to rural populations".
Riskier to be rich: Most STDs are associated with being poor and uneducated. HIV in Africa is associated with urban living, having a good education, and having a higher income. In one hospital in 1984, the rate of HIV in the senior administrators was 9.2%, compared with the average employee rate of 6.4%.
The authors conclude:
At issue in a reevaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic.
At the very least Africans deserve what even Western junkies are provided – clean needles. Maybe someone should set up a needle exchange program for African healthcare providers.
UPDATE: A reader who once practiced medicine in Africa sends the following:
I worked four years in two African countries twenty years ago. Let me tell you the facts.
One, many untrained or minimally trained people set themselves up in practice, including traditonal healers. In our area, the N’gangas and the local anti government guerllas would give penicillin shots, and vitamin B shots. This was before HIV waas recognized, of course. I suspect even today a lot of people get shots from these folks, or other treatments (see below) instead of going to a clinic. Needless to say, they don’t sterilize needles.
Second, our clinics "sterilized" needles over a coleman type stove, boiling water, not a autoclave. Our clinics were run by people with 7-10 years of school and four years medical assistant training. They tried hard, but I don’t guarantee they sterilized everything properly.
Third, although we were rich enough to use sterile needles each time, we often reused the same syringe over and over. Glass syringe, of course, and took the needle from a metal autoclaved box where they were lined up one by one.
We rewashed dressings: If they were very dirty, we burned them, but the parts that weren’t touching skin we redressed. But a wound from the outside would often come in dressed with a rag. And we were rich: I usually had gloves, (read the first chapter of When the band played on, where the doctor did not have gloves)
Finally, traditional medicine treated pain with "muti cuts". We could always tell where it hurt, because there were shallow cuts where herbs had been rubbed in. It’s similar to moxification, i.e. counterirrtant therapy for pain. The local women often had scarification for cosmetic reasons. They made shallow cuts, used some herb, and had lovely decorations of keloid tissue on their abdomens. I doubt any of these knives were sterilized.
We DID see syphillis and other STD’s back then. But not at the rate that one sees HIV nowadays. Genital sores increase transmission, of course, but most cases came from the cities, so I suspect some cases are indeed due to partially trained people giving shots.
In other words, don’t blame the hospitals and clinics. Blame poverty.
She brings up a point that I didn’t make clear enough in the post, and which the researchers also mention in their paper – a lot of healthcare in Africa is done by people with little training. Of course poverty is the reason they reuse needles, but you would think that providing disposable needles and educating the people who use them would be a priority of the same international aid organizations that provide the medications and the immunizations.
A study by H. Birungi made similar observations regarding personal needle use:
The basic argument is that the weakening of state institutions of health care has been accompanied by a loss of trust in the treatment offered there. In addition, the massive anti-AIDS education campaigns which have warned people against the dangers of sharing unsterilized needles, have reinforced existing mistrust in public health facilities and induced families to seek care from people they know and using injecting equipment over which they have personal control.
If many families are sharing needles and one family member is HIV-infected, it would explain why there are so many children catching HIV. In the BBC article from the same UNAIDS scientific advisor:
It would cost $290 million to ensure a clean needle for every medical treatment or vaccination in the world in two years’ time, research shows.
Surely some of that $15 billion could go there.
ABC
It’s just basic common sense. And it works. Sadly, what worked so well in Uganda is being undermined, and the government is being pressured to emphasize condoms at the expense of abstinence and fidelity, writes Harvard researcher Edward C. Green in the Weekly Standard. Under "C", however, another item should be added: ‘cides. Microbicides, that is. The reality is that men hate wearing condoms, so microbicides should be emphasized just as much as condom use, if not more.
Eschew Receptive Anal Sex
This is where the CDC falls short. In this table of AIDS cases, the data focuses on the who but not the what. Even so, for heterosexual contact, the risk factor is not known in 81% of the cases. Also not tabulated is the type of sexual contact (oral, vaginal, anal) which caused the infections. This is a disservice since the odds of catching AIDS via receptive anal contact are significantly higher than the other forms, up to 20 times higher than the vaginal kind. In a study by Daniel Halperin of UCSF:
Studies of heterosexual HIV transmission have consistently found anal intercourse to be a highly predictive risk factor for seroconversion. Yet most AIDS prevention messages targeted at heterosexuals, presumably influenced by cultural taboos against acknowledging this sexual practice, continue to emphasize vaginal and, increasingly, oral sex transmission. The health risks of anal sex appear to be severely underestimated by a substantial proportion of sexually active women and men in North and Latin America as well as parts of South Asia, Africa, and other regions. Among heterosexuals reported rates of condom use are nearly universally lower for anal than for vaginal intercourse. This review examines anal sex among the general population, including its prevalence in various world regions, related sociocultural factors, and other associated health problems including anorectal STDs, Hepatitis B infection, and HPV-related anal cancer in women. U.S. survey and other data suggest that, in terms of absolute numbers, approximately seven times more women than homosexual men engage in unprotected receptive anal intercourse. Research among higher risk subpopulations, including bisexual men, injecting drug users, female sex workers, inner-city adolescents, and serodiscordant heterosexual couples, indicates that persons particularly at risk of being infected by or transmitting HIV are also more likely to practice anal sex. Considering this finding, along with the much greater efficiency for HIV infection as well as lower rates of condom usage, a significant proportion of heterosexual transmission in some populations is due to anal intercourse. This typically stigmatized and hidden sexual practice must be given greater emphasis in AIDS/STD prevention, women’s care, and other health promotion programs.
In a roundtable discussion, Halperin expands:
Recently, I’ve been trying to estimate a ball park figure of the percentage of infection among women that could be attributed to anal as opposed to vaginal sex. Now, I have only begun to develop a rough model and I think it’s going to be quite difficult to come up with any definitive statistics at this point. But just roughing it out — given what we know generally about prevalence of anal intercourse among adult women, combined with the finding that there is less condom use for anal sex than for vaginal sex, and the much higher efficiency of anal vs. vaginal transmission — anal sex could potentially account for half or more of all heterosexual transmission in, for example, Brazil, and that’s using some fairly conservative assumptions.
Now in the U.S., I would guess it could be as high as a third of the total of heterosexual infection in the US. It’s conceivable. I’m not saying that’s definitive, but, it’s certainly plausible. If we leave out oral sex, since it’s not really significant in the aggregate, and look at the prevalence data of the Laumann study and others, one gets the sense that, at a minimum, approximately one out of every 100 heterosexual sex acts in the US are anal intercourse. However it depends on what heterosexuals you’re talking about because we have found that higher-risk subgroups typically report a higher prevalence of anal sex and are more likely to have STDs or HIV. So let’s say there are at least 100 times as many vaginal as anal acts. But if the efficiency of HIV transmission receptive anal sex is approximately, say, twenty times higher, which would certainly be in the range of those few studies that have tried to measure this, then you could conclude that at least one fifth of all heterosexual HIV transmission in the U.S. would be due to anal sex. But then when you factor in that anal sex has a significantly lower frequency of condom use attached to it, we could be getting up to 30 percent or more. Now these are just rough ballpark figures based on an very crude model, but I think we should begin to start looking seriously at such figures in order to get the word out that heterosexual transmission from anal sex is probably more common than we might think.
What we do know is that, unless there are open sores on the penis, the odds of female-to-male transmission are close to zero according to a study by Padian-Shiboski-Jewell. The odds of catching HIV through oral is similarly low. In healthy women, the odds of catching the infection through vaginal sex is also low. The King County website explains it well:
Worldwide most new infections result from sexual transmission, but not all sexual practices are equally likely to result in HIV transmission. It is impossible to precisely estimate the individual risks of each sexual act. The likelihood of transmission depends greatly on the chance that a partner carries HIV, the stage of that person’s infection, and the presence or absence of other sexually transmitted diseases. Although much is still controversial, we do know that:
- HIV is commonly transmitted sexually by penile-anal intercourse. The receptive partner (bottom) is at much more risk, but the insertive partner (person putting his penis into the anus) can also get infected.
- HIV is commonly transmitted sexually by penile-vaginal intercourse. The female is at more risk, but the male partner also can get infected.
- HIV can be transmitted by oral sex. Oral sex is much less risky than anal or vaginal sex.
- Other factors can affect transmission risk: the presence of other sexually transmitted diseases (STDs), viral load, condom use and douching.
Anal sex is the most efficient means of sexual HIV transmission…The rectal mucous membranes seem to have more receptors to bind HIV and the tissue is more easily traumatized, leading to more easy access for HIV transmission.
Unless a woman already has an STD or genital ulceration, the odds of catching HIV are low via vaginal sex, less than 1 in 1,000 (sort of like playing Russian roulette with gun containing 1,000 chambers). Vaginas have thicker membranes than rectums and are less susceptible to bleeding.
I’m not sure about the quality of the source, but there is this from a former AIDS researcher, quoting other scientific studies:
Likewise, numerous studies have demonstrated that women who have sex with HIV-positive men are at far greater risk if they engage in anal intercourse. Nancy Padian’s partner study done in the mid-1980s found that, for females in long-term relationships with infected men, those having anal intercourse were 2.3 times more likely to acquire infection than those who had vaginal sex only. This does not mean that anal transmission risk on a per-contact basis is only 2.3 times greater than vaginal. It means that women in the study who engaged in any anal intercourse were 2.3 times more likely to become infected than those who did not.
From a later study of a similar nature she reported that 30% of the women who had any anal sex became infected compared to 14% of those who did not. A 1988 article in the Journal of the American Medical Association advised physicians that patients should be told to avoid anal intercourse. The following year the same publication cautioned that HIV is transmitted by "a particular form of sexual behavior, anal intercourse."
Sexual practices in Africa cannot be terribly different than anywhere else. If the principles apply here, they should as well over there. Human nature doesn’t change with the continents. A study by Brody-Potterat compiled available sources which suggested that anal sex is just as commonplace in Africa as Europe and the United States.
Public health authorities have long believed that the preponderance of AIDS cases in Africa are attributable to ‘heterosexual transmission’; most people silently assume this rubric to indicate penile–vaginal intercourse only. Recent epidemiologic analyses suggest that the majority of HIV cases in sub-Saharan Africa may be due to non-sterile health care practices. The present paper reviews the anthropological, proctologic, and infectious disease literature, and argues that both homosexuality and heterosexual anal intercourse are more prevalent in Africa than has traditionally been believed. The authors hypothesize that perhaps the majority of HIV transmission not accounted for by iatrogenic exposure could be accounted for by unsuspected and unreported penile–anal intercourse. Given the authors’ findings, properly conducted studies to measure this HIV transmission vector, while controlling for iatrogenic exposure confound, are clearly warranted in Africa and in countries with similar epidemiologic characteristics.
This section is running a little long, but the point is that following A and B (assuming no infected needles or body piercings) is nearly foolproof in preventing AIDS. Past that, it’s a game of odds. Condoms and microcides are the next wall of defense, but there are risks. Absent the C’s, the next riskiest behavior is the receiving end of anal intercourse, gay or straight. Therefore, another letter should be added so that the odds of catching this malady are minimized.
One other factor merits discussion, and that is infection rates, and which could be a counterargument to the one made here. In Medical News Today:
Conducted by a group of investigators led by Maria J. Wawer of Columbia University, the study is the first to present empirical data showing that the rate of heterosexual HIV transmission per coital act varies over the course of HIV infection. The investigators found that the risk of transmission was highest early in infection, then dropped, then rose again late in infection.
Wawer and colleagues followed a cohort of over 15,000 adults living in rural villages in Rakai, Uganda. From this population, they retrospectively identified 235 heterosexual couples in whom one partner was infected with HIV and the other partner was uninfected and monogamous. Study participants provided a blood sample and answered questions about their health and behavior, including questions on number of sexual partners and coital frequency, at 10-month intervals for up to 40 months.
From analysis of these data, the researchers found that during early infection (the approximately two-and-a-half month period after HIV seroconversion), the average rate of HIV transmission was five- to twelve-fold higher than during established infection. The infection rate was 8.2 per 1000 coital acts during early infection, compared to 0.7 to 1.5 per 1000 coital acts during established infection. The rate rose again during late-stage infection, 25 to 26 months prior to death, to 2.8 per 1000 coital acts. Among partners with newly acquired HIV infection, more than 40 percent transmitted to their partners within approximately 5 months.
These results reflect transmission rates for heterosexual vaginal intercourse only, the authors noted, and cannot be applied to HIV transmission via anal intercourse or injection drug use, since neither behavior was reported by study participants. In addition to early or late infection, other factors associated with increased transmission from the HIV-infected partner were younger age, increased viral load, and genital ulcer disease.
The study did not cover anal intercourse, but it would not be unreasonable to infer that the transmission rates for recipient anal sex would be five- to twelve-fold higher as well. Like I wrote, after A and B, you’re rolling the dice.
Freedom
The best path toward AIDS treatment and prevention is to push Africa out of squalid poverty, and the best path toward ridding poverty is freedom. The fruits of free societies are the rule of law and free market economies. As this map shows, there is not country in Africa with a free economy. Bush has been great about spreading the message of freedom and democracy to the Middle East and former Soviet client states. It’s time to export that message to Africa. Way back in 2000 and well before 9/11, Jonah Goldberg penned a neoconnish piece on Africa here:
The Left talks about helping Africa, but what they invariably propose is transferring American wealth to the corrupt kleptocrats they meet at symposia and junkets (it’s a phenomenon similar to the crushes American intellectuals developed for Soviet Communist Party members they met at Embassy cocktail parties). Whenever someone proposes something that would either hold kleptocrats accountable or foster real development through markets, someone on the left screams about racism or colonialism. Meanwhile, the Right just doesn’t talk about helping Africa much at all.
I think it’s time we revisited the notion of a new kind of Colonialism – though we shouldn’t call it that. I don’t mean ripping off poor countries. I don’t mean setting tribes against one another and paying off corrupt "leaders" to keep down unrest. I mean going in — guns blazing if necessary — for truth and justice. I am quite serious about this. The United States should mount a serious effort to bring civilization (yes, "Civilization") to those parts of Africa that are in Hobbesian despair. We should enlist any nation, institution or organization — especially multinational corporations and evangelical churches as well as average African citizens — interested in permanently helping Africa join the 21st century. This might mean that Harvard would have to cut back on courses about transgender construction workers. And it might mean that some churches would have to spend more time feeding starving people than pronouncing on American presidential candidates.
We should spend billions upon billions doing it. We should put American troops in harm’s way. We should not be surprised that Americans will die doing the right thing. We should not be squeamish, either, about the fact that (mostly white) Americans will kill some black Africans in the process. Yes, this would be a display of arrogance of historic proportions, even a crusade. But it wouldn’t be a military one. On one hand, this cannot be merely an armed invasion, but on the other hand it must not be some UN initiative which just shuffles poverty around. This would be America and its allies doing right as we see it.
Yes, this would seem imperial, for there would certainly be wars declared against us. French writers would break their pencils in defiance of the American Empire. Kofi Annan would need a pacemaker. Pat Buchanan would move to Canada. But being imperial is not necessarily a bad thing. The British Empire decided unilaterally that the global practice of slavery was a crime against God and man, and they set out to stop it. They didn’t care about the "sovereignty" of other nations when it came to an evil institution. They didn’t care about the "rule of international law," they made law with the barrel of a cannon.
Recently, we’ve heard a lot from the Left about how great Cuba is because it has free health care. American liberals are perfectly willing to countenance Cuba’s state-sanctioned murder and the abrogation of virtually all civil rights in exchange for free mammograms and tonsillectomies. Ending poverty and hunger — barely — ought to be worth a mighty price for these men and women who spout daily about the right to burn flags and receive government payments for artfully arranged fecal matter. One wonders what they would be willing to accept for African children to grow up with arms and families intact.
As for what conservatives would be willing to accept, I have no idea. But I have a sense quite a few of them will tell me.
He expounds a little more on solutions here. Not that I agree with all of it, but a good place to start would be Darfur, especially after reading "reports" from the children of that godforsaken region.
Other Avenues and Alternatives
Assuming the numbers are accurate, five hundred million catch malaria every year and one million die from it. Most of those who die are from Africa. The National Ledger:
"At present malaria remains the infectious disease that takes more lives of children in Africa than any other – three times as many as HIV," said Ann Veneman, the executive director of UNICEF noting that "Much more must be done."
"Malaria is treatable and largely preventable with the tools available now," said WHO director general Lee Jong-Wook.
The treatment for malaria is a fraction of the cost compared to HIV/AIDS. The point is that some of that $15 billion should be used to address other lethal but more treatable maladies. Here’s another tack, courtesy of the Economist:
This week, scientists from the Institute for OneWorld Health, the first not-for-profit pharmaceutical company in America, presented the results of a large clinical trial at the Third World Congress on Leishmaniasis in Palermo, Italy. Leishmaniasis is a parasitic infection transmitted by the bite of a sand fly. The trial shows that an antibiotic called paromomycin is effective for treating the most dangerous version of the disease, visceral leishmaniasis, which affects 1.5m people around the world and kills 200,000 of them every year. Those data are obviously important for medical reasons. But they are also important as a demonstration that the institute’s novel approach to drug development is working.
About 90% of the planet’s disease burden falls on the developing world. Yet only 3% of the research and development expenditure of the pharmaceutical industry is directed toward those ailments. The rest goes towards treating diseases of the rich. In 2000, Victoria Hale (pictured above), founded the institute to help tackle that discrepancy. She knew from her work as a scientist in the pharmaceutical and biotechnology industries, and subsequently as an official at America’s Food and Drug Administration, that numerous promising drug-development projects—particularly for diseases of the poor—are dropped for lack of funding. She reasoned that there was a gap in the market, between academically inclined university departments and fully fledged pharmaceutical firms, for an organisation that would identify such orphans, get their owners to donate the intellectual property if they were still in patent, raise development funding from non-commercial sources, and arm-twist researchers to contribute their expertise to the development process pro bono.
Blast corporate America all you want, but the main benefactors of this venture are the Bill and Melinda Gates Foundation and the Lehman Brothers Foundation. Bully for them, and it’s about time that more research monies be used to save the lives of the disadvanted than for stiffening the penises and lifting the blue moods of the well-off. The Institute for OneWorld Health needs a lot more exposure, and some of that $15 billion wouldn’t hurt.
Whew. I’m outta words. If you’ve gotten this far, the point is that ABC isn’t enough. We need to know the scope of the problem. We need to discourage the use of infected needles. We need to emphasize each of the letters–A, B, CC and E–equally. Other treatment avenues should be tried. Finally, none of these things will really take if these societies remain in abject poverty. It’s time to export freedom and democracy to Africa and rid the place of all those two-bit penny ante tinpot despots.
CB, thank you for an awesome, thoughtful post. Since the rules say I can’t leave a comment praising a righty without at least one quibble, I think your citation to Jonah Goldberg detracts from the post. Who does he really think he’s going to persuade that the US needs to start a long-term occupation of an entire continent? What a nitwit.
But compared to the AIDS denialism coming from Dean’s World, your post gives the reader a sound basis to recognize that even large-scale health organizations succumb to the bureaucratic impulse and advance contamination theories that support their mission.
arrgh. there’s enough misery to go around on this planet; why do we all spend so much time fighting over turf? (rhetorical question.)
thanks again.
Wow.
I cannot add to this, but I certainly thank you for your effort.
Now I know where you’ve been for the past month; compiling this. A lot to think about here and a good read, even if I distrust some of the sources. Wish I had more time to ponder it now.
Good post.
1) I somehow can’t picture the president of any country putting the line “Eschew recipient anal intercourse!” but that’s okay. 😉
2) Don’t overlook the possibility of vaginal transmission though. The risk is NOT that high for a given sex encounter when neither partner has an STD, but when another STD is present it increases a lot skyrockets–and STDs rates are very high in some parts of Africa; I remember being floored by the numbers when I did my college senior essay on AIDS & South Africa in 2000. A lot of these diseases are treatable with penicillin, but needless to say access to health care in Sub-Sahran Africa is not the best.
3) Like you said, the needle thing strikes me as one of the very easiest things to fix.
4) Two more good things about microbicides:
–you sort of alluded to this, but unlike condoms they are entirely within the woman’s control; I think it’s possible that they’d be undetectable to a man. In a place where women’s status is low, this is huge.
–As far as I know no one has a religious objection to their use.
As the Slate piece mentioned, there’s a bill in the Senate right now to support microbicide research. If you want to write your Senators in support, it’s S. 550, the Microbicide Development Act.
Right now it’s just supported by the usual liberal suspects (Bingaman, Boxer, Cantwell, Clinton, Corzine, Dodd, Durbin, Feinstein, Kennedy, Kerry, Lautenburg, Leahy, Mikulski, Murray, Obama, Schumer) and two moderate Republicans (Smith, Snowe). That’s not going to get it to a vote. But I see no reason why this would have to be a partisan issue.
You can look it up here
Charles, you are not ruining this site. Good post.
Good post.
One aspect of the difficulty with ABC is the opposition of the Catholic church to condoms – both honest opposition, and outright lying.
I’m told that the female condom is very popular as a means of HIV prevention, in the parts of southern Africa where the Catholic church is not opposing use of any condoms.
It seems unlikely, furthermore, that the new Pope will change the Catholic church’s present stance.
A wonderful update on the topic, Charles…I’ll echo those thanking you.
I do, as per my contract with the VLWC, however, have a few points of, well, discussion, let’s call them.
With regards to the overestimating of HIV rates: If the emphasis on prevention has been geared toward the wrong behavior, why are the estimates of infection lower than expected? Yes, I know the models were faulty, but isn’t it also possible that the prevention emphasis has actually contributed to the lower infection rates?
For example, data like this need clarification:
But, when was the first reported case of HIV in Zimbabwe? Were these “infections” that increased or “diagnoses”? Since HIV can remain dormant and the infected person symptom free for years, it’s not at all unlikely that condoms did contribute to a decrease in HIV infections even though there was an increase in diagnoses. This may not be the case, but the description here doesn’t answer it.
At the very least Africans deserve what even Western junkies are provided – clean needles.
This would appear to be an immediate, prudent improvement in the approach.
the government is being pressured to emphasize condoms at the expense of abstinence and fidelity,
Why is this seen as an either/or? This notion that if you emphasize condom use, you can’t also emphasize fidelity or abstinence has never made sense to me. Take it from someone who has lived this his entire sexually active life: both are important. Both. It’s foolhardy to think abstinence and fidelity are foolproof, because they are not realistic. Human nature being what it unfortuantely is.
And this is misguided, IMO: “Eschew Receptive Anal Sex” (not only is it misguided, it’s somewhat poorly worded…anal sex requires two people, and so blanketly emphasizing the “receptive” aspect is actually redundant unless there’s some new way to do this I haven’t heard of). As the study points out, there is already a taboo against anal sex in Africa, so “eschewing” it is unlikely to make much difference. The opposite is in order. Discuss anal sex and add it openly to vaginal and oral sex as behaviors for which it’s important to use a condom.
Actually, the part that made me go WTF was the sally against body piercing. When correct sanitary procedures are observed, your chances of spreading any bloodborne diseases through getting pierced are zero. That part sounded more like an attempt to piggyback a personal distaste for body modification onto an otherwise more-or-less decent post.
The emphasis, as with most other things, should be on teaching people the proper precautions to take to ensure that piercings are performed safely. The added bonus from this is that the knowledge will spill over into other parts of life: a person who learns that a clean, sterile needle is necessary for body piercing might just stop to apply that knowledge somewhere else.
Edward: . . . anal sex requires two people, and so blanketly emphasizing the “receptive” aspect is actually redundant unless there’s some new way to do this I haven’t heard of . . .
Ever seen Requiem For A Dream?
Good, informative post, Charles. I’ll read it a second time to really take in all the info being offered. One thing I noticed, though: It’s worth calling out Medpundit on his glib reference to “Western junkies” getting clean needles. As effective as needle exchange programs can be, we all know that a) there are very few well-funded needle exchange programs in the U.S. at any level, b) several states ban the possession of syringes without prescriptions and 46 consider possession of a syringe without a “clear medical use” a violation of drug paraphernelia laws, and c) Federal law prohibits federal funding of needle exchange programs, in the misguided belief that it’s more important to ineffectively fight the War On Some Drugs than it is to help keep people from dying. Nothing to do with your post per se, but it’s worth recognizing anyway.
Also, a piece of constructive criticism? In this day and age, referring to Africa as a “dark continent” in any context, no matter how cleverly, carries a colonialist tone that might turn some people off to reading past that graf. Just a thought.
Finally, Jonah Goldberg is an ass. Nice to know that he’s willing to kill as many Africans as it takes to Civilize them, though. It’s also amusing to see him refer dimissively to ” . . . men and women who spout daily about the right to burn flags and receive government payments for artfully arranged fecal matter . . . ” as opposed to wanting to help Africans. Assuming that he’s referring to Chris Offili’s Virgin Mary, Offili never received any government money — not from ours, anyway, being British and all — and he only began using dung as a medium after traveling to Zimbabwe and after learning more about his own Nigerian roots. I guess actual, real African culture isn’t too important to old Jonah.
Sorry for the diversions. Good post.
Ever seen Requiem For A Dream?
Yes…vicious movie…and that scene in particular was brutal…but I don’t see how that would transmit HIV.
Charles, this is definitely the best post you’ve written for ObWi. (I have some major criticisms of the Jonah Goldberg article you cited, but no time to go into them. Other than that, excellent job.) I had read some of this information previously, and was wondering if it would ever get wider play.
CB, thanks for this post, which will take a lot of digesting.
ObScientistCarp – modelling is hard, but so is sampling. One needs to treat the latter skeptically too, esp. in politically-charged areas. And no measured or predicted number means anything without an associated uncertainty.
Generally good post, although I’ll second Jes’s comments on ABC, citing 1 group’s comments supporting greater C at the expense of A and B, while ignoring another group’s acts to vilify C seems one-sided at best.
“If folks cannot abstain, then the next best route is to be faithful.”
This is clearly not true. The next best route is to wear a condom, combined with testing your partner and yourself for STDs well before intercourse. In nations where STD tests are neither affordable nor available, “being faithful” offers little or nothing in the way of protection — certainly not enough to put it ahead of condoms.
A couple of general comments and some specific responses. I was on jury duty for six full days and it blew up my schedule. My paying job is at a 50 hour/week clip, and adding four to five kids’ baseball games a week and assorted other commitments, my ability to post is temporarily slammed. Plus, this one took a little time.
Edward, I appreciate your responses, particularly since I have no experience on the thing I’m recommending Africans to eschew from. While it does take two to tango, not knowing the HIV status of the person on top is a form of Russian roulette, particularly since the practice (unprotected) is riskier by a factor of 20.
If the emphasis on prevention has been geared toward the wrong behavior, why are the estimates of infection lower than expected?
It comes down to poor information on the quantity of cases and poor information on transmission. They’re coming from the same sources (UNAIDS and a few other groups) and both sets of faulty data are slanted toward maximizing aid to the affected countries. Inflating the quantities and misrepresenting transmission rates accomplishes the same thing. They should be getting busted on their slipshod ways, because over the long term their distortions are going to be counterproductive. Malaria and tuberculosis, which kills a whole bunch more people, don’t get the resources they should and more will die because of this disservice.
This is clearly not true. The next best route is to wear a condom, combined with testing your partner and yourself for STDs well before intercourse.
If you do A or B, Anders, C is unnecessary.
I think what Anders may mean is that it takes two people who are constantly faithful for “B” to be foolproof, and it is possible & probably not so terribly uncommon for one of these two people to claim that they have been nothing but faithful, when this is false.
It often doesn’t seem to occur to the Catholic Church and other opponents of C that it is possible for one spouse to be faithful, and the other not to be.
Charles: thanks for this. A few responses, which I’m going to make, I think, in several comments.
Diagnosis: It’s not really diagnosis that’s the problem, it’s computer modeling. Any attempt to estimate disease prevalence in a population must either test the entire population or extrapolate from some sample, and any extrapolation involves the possibility of error. This is particularly serious in Africa, where lots of the population is inaccessible and unknown to many of the people who do the extrapolation (even if they’re from the country in question), and in which moreover a lot of countries do not collect adequate statistics even on basic things like mortality (which can help one decide how to extrapolate something else.)
“By wildly overstating these HIV/AIDS fears, organizations with vested interests get more money, sadly diverting funds from malaria (350 million afflicted per year) and tuberculosis (two million afflicted per year), both of which are eminently more treatable at far less cost, saving more lives on par.” — this sentence suggests that the overestimates are deliberate; I know of no reason to think this.
Transmission: You write: “If the primary means of HIV transmission in the U.S. are receptive anal intercourse and intravenous drug use, why should it differ in Africa?” Actually, there are lots of reasons to think that it would. The health status of African and US populations are very, very different. Among the differences are several which affect susceptibility to disease in general or HIV in particular: malnutrition, rates of TB and STDs, and so forth. I do not know all the evidence, etc., but it’s perfectly conceivable that any or all of these could explain why women in this country tend to be able to ward off HIV when it tries to infect us via vaginal intercourse, while African women are on the whole a lot less successful.
The report you cite is one side of an argument. The summary of the other side is here. I am not competent to judge them on the merits (though I will be better placed to do so in six weeks or so, since I’ll be taking a course in the epidemiology of AIDS — have I mentioned recently that I love my job, with its access to courses at the best school of public health in the world?). But it is not at all obvious to me that the side you rely on is correct.
If it isn’t, then statements like this are wrong: “Basically, groups like WHO and UNAIDS are irrationally scaring the world about the prevalence of AIDS in Africa, and they are distorting how the disease is getting transmitted.” Again, this asserts intentional deception, which I don’t think that you’ve shown at all.
(FWIW, the last cite I gave — the expert consultation on HIV transmission, includes the following quote:
This doesn’t sound much like denial to me.)
More later. But thanks.
Excellent post, Charles.
Charles: If you do A or B, Anders, C is unnecessary.
But given that A and B both have higher failure rates than C, it seems foolish to ask people to depend on A and B rather than C.
Charles: nice job.
A thought on abstinence: Yes, it is foolproof, and yes, you provided backups. This thing called human nature; is it preventable?
I have no opinion on the idea that AIDS occurence is inflated, but I would mention that if it is, that is irrelevant to the lack of funding and attention paid to tuburculosis and malaria, except as a function of the Western world being essentially bored with the latter two. I’m happy to fund the latter two adequately and overfund the first. Or, overfund all three. Let’s live a little.
Third point: I’ve never encountered the strap-on kind.
Sorry. I always add levity at inappropriate times.
Or, maybe I didn’t.
When you have an unwieldy acronym like DEABCETA, the trick is to make up a sentence where each word starts with the next letter in sequence.
For example, “Don’t Eat A Big Cheesy Enchilada This Anniversary.”
I suggest holding a reader contest to come up with a better version.
Moving right along: I don’t know who MedPundit is, other than what she writes in her profile (not much), but I’d be skeptical of the opinion of anyone who doesn’t know that medical professionals in Africa often reuse needles. Figures on per capita spending on health care in 2002 are here. For sub-Saharan Africa, the average is $31.9/person/year. That’s just over thirty dollars a person. And that includes South Africa, which spends $206/person/year. Uganda, by contrast, spends $18; Malawi spends $14, and Mozambique spends $11. Per person. Per year. Not a lot of money for needles there.
In any case: I would have to get down and dirty with the statistics in the study cited in order to figure out what their case is like. I read the study (and its two companion pieces), and it was neither clearly convincing nor clearly wrong. However, the part Medpundit cites after saying this: “That evidence, according to the authors, was not only ignored, but suppressed by the world public health community:” — is presented in the study not as conclusions for which they provide evidence, but as speculations about what might account for the fact (which the authors take themselves to have established) that a consensus emerged that was not supported by the evidence at the time. That is: they give no evidence for the claim that anyone actually was motivated by the thought that heterosexual transmission would get more press, by ideas about African sexual behavior, etc. This matters.
(I gather there are studies underway that will try to gather evidence on the role unsafe medical practices play in HIV transmission in Africa, but that they aren’t out yet.)
It’s also not right to say that donor organizations have just ignored the problem of unsafe injections, etc. See here, here, here, here, here, here; and hey, just last month a consortium of groups working to eradicate measles gave 11.2 million auto-disposable single-use syringes to Mozambique (along with the vaccine they’ll be used to administer, and other things.)
I echo everyone else who has said that it’s not necessary to choose between A, B and C. In any case, with our government having earmarked a billion dollars a year for abstinence programs, it’s hard to see why those programs would have disappeared. But for a different view on what’s up in Uganda (from someone whose work is quoted with approval in the RSM study you cite), see here.
I know nothing about anal sex in Africa. I will say that if you’re using ‘free economy’ to mean ‘completely free according to the Heritage Foundation’, if follows that most of Western Europe doesn’t have free economies either, which is absurd.
Honestly, though, it was such a great post until Jonah Goldberg elbowed his way in. I mean, there are basically two things going on in his article. First, a completely ludicrous proposal to colonize Africa; second, completely mindless snark against liberals. If I cited with apparent approval some article that said, for instance, “If conservatives wanted to do something about AIDS, they’d have to put down the remains of those uninsured infants they’ve been munching on, release their death grips on their wallets, and fork over some cash to those “poor people” they’ve heard people mention in disapproving tones after the board of directors’ meeting; poor people who live in distant countries that, until now, they have thought of only as the locus of mineral resources to be exploited by the multinational corporations they head” — well, I don’t think it would strike you that I was (a) intending to be taken seriously by you, or (b) quoting a trustworthy source. For some unfathomable reason, I have a similar reaction when I read about Harvard’s silly little courses about transgender construction workers, or my supposed fondness for kleptocrats. (I will stack up my record for denouncing kleptocrats and dictators against Jonah Goldberg’s any day.)
We should be spending more fighting malaria. But that doesn’t mean we should be spending less fighting AIDS.
Still, great post, except for Jonah.
A couple of remarks:
The advisor was worried more about reductions in condom usage–clinging to UN conventional wisdom…
Which I’m not convinced has been undermined by the study you cited, for much the same reasons as hilzoy. Though I look forward to her reports back from the wars.
[ABC] is just basic common sense. And it works. Sadly, what worked so well in Uganda is being undermined…
As I linked in a previous thread, ABC does not in fact work, at least not as described. [I can rustle up the links again if need be.] Specifically the A and the B parts didn’t seem to have any noticeable impact on AIDS transmission; only the condoms had a measurable effect.
Note: I’m speaking here of the real-world history of Ugandan AIDS transmission, not of a hypothetical scenario wherein people are actually perfectly abstinent and perfectly faithful. It’s certainly possible that we should continue pushing the AB parts of the equation on the grounds that to not to do so would exacerbate the problem — for precisely the idealistic reasons you cited — but so far the evidence does not support the contention that they actively curtail it either.
The best path toward AIDS treatment and prevention is to push Africa out of squalid poverty, and the best path toward ridding poverty is freedom. The fruits of free societies are the rule of law and free market economies.
While I’m certainly sympathetic to the aims of liberalizing (in the generic sense) Africa and helping them attain both rule of law and robust economies, I’m not at all convinced that we can chart out the path in the simplistic way you’ve done here. [Added in proof: pace hilzoy, nor am I convinced of what you mean by “free”, either as a society or as a market economy.] Plus, the Jonah Goldberg cite seriously undermines the credibility of the argument, both for the cutesy slams against the Left, the UN and the French — ever-reliable whipping boys all — and the ludicrous glorification of the British Empire.* And I say that as someone unwillingly sympathetic to the idea.
All that said, a worthy post. Kudos.
* Which isn’t to say that the British Empire was all bad, but the savior of those “huddled in Hobbesian despair” it was not.**
** And this? “The British Empire decided unilaterally that the global practice of slavery was a crime against God and man, and they set out to stop it”. Is just plain laughable. Seriously. Did he just sleep through the history of the 19th century or what?
And it’s time to renew my seemingly-eternal question: how much of the $15 billion promised for African AIDS prevention has a) been appropriated and b) spent? Also, c) what are the restrictions on its use?
A very impressive piece of work. I don’t know enough about medical related things to meaningfully critique it, but it looks like you did a lot of research.
I have to agree with those who think Goldberg is full of it. While he is right that giving large aid packages to kleptocratic governments is pissing money down a hole, I can’t see the First World as having the spare resources for such a humongous task without a level of sacrifice which would simply destroy our own liberal societies.
And I can’t see the Chinese just sitting back and hanging out while the US and Europe overran Africa and bent it to our will again.
I agree that Freedom and liberty need to be promoted in Africa; healthier societies will help Africans to solve their problems more effectively. But I don’t think what he’s proposing has any reasonable chance of turning into anything but an abject disaster.
The days in which Africa can be conquered on the cheap by small scale armies is long over.
“If you do A or B, Anders, C is unnecessary.”
If you do A, you have no use for C as a matter of definition. Doing B without C (and without STD tests) is a total crap shoot. Not only do you have to rely on your partner to be faithful in return, but you have to blindly hope that he or she was not infected when your faithful relationship began.
Condoms are far, far more safe than “being faithful”.
Hilzoy,
On the diagnosis side of things, women in Africa may be more vulnerable to HIV due to malnutrition or other diseases which may have already weakened their immune systems. There may also be higher incidences of STDs or genital ulcerations, or not. However, the fundamentals for HIV transmission should not be that different. To catch HIV, it still boils down to infected bodily fluids entering someone else’s bloodstream.
I didn’t present the WHO side of the argument because theirs is the CW and the commonly accepted position. Your link is classic WHOism. They state that the primary mode of transmission is “unsafe sex” but fail to address the type of sex involved. Second, their data on transmission rates to children is highly suspect, as the AIDScience article above states:
Your link also shows that ridiculous 26.4 million estimate. As for whether there was “intentional deception” on the part of WHO, it is an open question. It works to their benefit funding-wise to present bloated estimates using computer models that are jiggered to the high side.
I will say that if you’re using ‘free economy’ to mean ‘completely free according to the Heritage Foundation’, if follows that most of Western Europe doesn’t have free economies either, which is absurd.
You can judge for yourself by checking out the map in the link, to see which economies in Europe are free. Virtually all are “free” or “mostly free”. In Africa, only 8 of the 47 countries on the mainland tilt to the “mostly free” side. This link provides more detail on a country-by-country basis.
Injection policy or not, WHO is too casually dismissive of infected needles as a means of transmission, given the conflicting data from the cited study.
Anders: If you do A, you have no use for C as a matter of definition.
You succinctly point out the lack of safety in B without C: the problem of A without C is that A has a known high failure rate even when we are simply counting those who decide to be A and therefore have no C available when A fails: it has an extraordinarily high failure rate when A is imposed from above on people who have not decided to use A.
Very nice Charles, however, I think the downplaying of condom use is not at all useful, which the ABC motif does. My understanding is that the condom approach in the sex trade in Thailand has been highly successful, but cuts in awareness programs and an inability to push condom usage into non sex trade sex has led to a resurgence of AIDS/HIV If the data shows this kind of reduction in Thailand, wouldn’t it be problematic to go in the opposite direction for Africa? Given that Thailand is organized enough (and ‘free’ enough, whatever that means) to develop its own data, you have to argue the tinfoil-ish notion that WHO is not only cooking African data, but also SEAsian data.. A second link here
But again, thank you for an excellent post.
Very nice Charles, however, I think the downplaying of condom use is not at all useful, which the ABC motif does.
Is it “downplaying” to recommend equal emphasis for each of the letters? What I’m suggesting is ABC, not abC.
A and B are less useful and less reliable than C: abC is the proper emphasis, though I like your further suggestions.
Actually Jes, I think that needs some clarification
A and B are more useful, but less reliable, and so C should be the ultimate emphasis. In other words, abstain, be faithful, but whatever you do USE A F*CKING CONDOM.
Is it “downplaying” to recommend equal emphasis for each of the letters? What I’m suggesting is ABC, not abC.
Not meaning to get all biblical on you here, but there is a reason why it is the Father, the Son and the Holy Spirit and not any of the other 5 possible permutations. Also, there is a reason why in Corinthians 13:13, Paul is impelled to point out that the last one is the most important.
And while this is not a complaint about your content, this site might suggest why adding more letters to ABC might not work out cognitively.
Given that A and B both have a higher failure rate than C, I don’t see that they’re more useful… but I think that’s just quibbling, since your last sentence? Pure poetry. 😉
In other words, abstain, be faithful, but whatever you do USE A F*CKING CONDOM.
Is there any other kind?
Given that Thailand is organized enough (and ‘free’ enough, whatever that means) to develop its own data…
And has been since at least 1992, when I visited Chulalongkorn University and saw a presentation there on Thailand’s burgeoning AIDS nightmare. They’ve probably spent more time, effort and brainpower figuring out how to politically/societally curtail the spread of AIDS than any other on the planet.
Finally:
Is it “downplaying” to recommend equal emphasis for each of the letters?
Yes, if the letters aren’t themselves inherently equal in effect. Given how quick you are to decry “moral equivalency” arguments, you really ought to have noticed that.
Jonah Goldberg penned a neoconnish piece on Africa here
Help me out a little here–is the armed re-colonization of Africa the sort of project a professed “neo-con” finds desirable? ‘Cause I frequently hear accusations of neo-con imperial grandiosity dismissed as mere paranoia.
Of course, for all the likelihood it will happen, Jonah might as well be dreaming of Star Trek as an African reconquista. But I am interested to hear Charles elaborate on other merits of Jonah’s plan, as he sees them.
A full response would be longer than the original, so I’ll just throw out a few bullet points:
(1) So-called “dry sex” is more common in Africa than elsewhere. This involves using astringents or absorbtive herbs to tighten or dry the vagina so as to increase the intensity of sensation for the male. It also increases HIV transmission.
(2) There is a major UN effort underway to attack the problem of Malaria, so this at least is being dealt with to some degree.
(3) Any index of freedom that places Saudi Arabia in the same category as Botswana is utterly amoral. Freedom to buy and sell in the absence of the freedom to worship as one chooses, or to speak one’s mind, or to engage in any of the myriad things that are forbidden by the Saudis which we take for granted is freedom only in the most twisted sense of the word. Economic freedom is *way* down the list of freedoms the US should be espousing. The fact that it constantly worms its way to the top, over fundamental rights like freedom of religion, freedom of expression, the right to a fair trial, and the right to equality before the law is an expression of the overwhelming power of economic interests in our country. HIV transmission could be drastically reduced by simply empowering poor women so that they are less dependent on men, and so are able to decline unsafe sex acts without the threat of financial devastation. Saudi Arabia is not a good model for this.
(4) Jonah Goldberg is a racist. His desire to save Africans from themselves is arrogant and ignorant in the extreme. Africans are perfectly well able to create stable and free societies on their own. The hideous mess outsiders see when they look at Africa is at least as much due to outside interference as to any native problems. Somehow the Goldbergs of this world can’t bring themselves to suggest that western nations and companies stop propping up dictators, or stop driving whole nations into crippling debt by lending to corrupt and authoritarian regimes. If the neocons are serious about spreading freedom and stability in Africa they only need to accept the principle that debts incurred by dictators need not be repayed when the dictators are displaced by democratic movements. Not only does this lift the burden from nations struggling to transition to democracy, but it also reduces incentives for lending to dictators. Furthermore, contracts signed by dictatorial regimes with multinationals need not be honored by successor democratic regimes. Again, not gonna happen. Why? because the megacorporations have too much power, so their toadies like Goldberg will work to keep the focus on the weak as the source of problems, rather than the strong.
But I am interested to hear Charles elaborate on other merits of Jonah’s plan, as he sees them.
I wrote that I didn’t agree with all of it. I consider his offering a pre-9/11 trial balloon for more assertive US involvement in Africa. When he wrote this, Rwanda had occurred six years earlier and, in 2000, there were few or no signs of substantive progress. Personally, I think the push for freedom and democracy is the right course. With the exception of Darfur, I don’t think we should get involved militarily at present, but you never know. There may be occasions such as an impending genocide or massive starvation where direct military involvement is the right thing to do.
Andrew Case: about repaying the debts incurred by dictators: I wrote about that here, arguing that we should make this change prospectively, and also not allow dictators to buy and sell their countries’ resources. If you weren’t reading this blog back then, it might interest you.
AID’s =Africa is developing,selves.