IPN Health Blog

UNAIDS: Science vs Spin

Following the release by the CFD of Jim Chin's paper on the Myth of a general AIDS pandemic, there have been some tectonic shifts in the AIDS policy world. This culminated in Dr Kevin De Cock of WHO's public assertion that there is minimal risk of epidemic HIV transmission in heterosexual populations outside of sub Saharan Africa. 

This is contra to the hitherto official position that it is only a matter of time before AIDS bridges from high risk groups into general populations.   As Prof Chin argues, such 'generalised' epidemics have not occured outside of Africa, and nor will they.

Needless to say, Dr De Cock is receiving a lot of flak from those who claim that such frankness simply gives succour to AIDS denialists and moral fundamentalists, and gives the impression that the fight is won. Partly as a result, he has been forced to issue a rather limp rebuttal, co-signed by UNAIDS.  UNAIDS is understandably worried that without an alarmist message on AIDS, the lavish funding the disease currently attracts may well soon dry up.

The AIDS pandemic still remains the most severe infectious disease pandemic in the world today, and UNAIDS is right to say that great efforts need to be made to tackle it. However, had UNAIDS been honest about the epidemiology from an earlier date, these unfavourable headlines would have never occurred.

The response to the AIDS pandemic has to be based on science and not spin.  UNAIDS is guilty of distorting the former, and relying too much on the latter. 

As a result, too much money has been wasted on pointless activities such as AIDS prevention programmes for youth outside of Africa. 

More worryingly for UNAIDS, such spin will cause the public will to distrust the word of such agencies. And without scientific credibility and trust, agencies such as UNAIDS are worthless.  AIDS patients  will be the real losers, rather than UNAIDS staffers, who can always find new jobs.

More spin from UNAIDS

This week the Commission on AIDS in Asia released its prediction that, without additional action, AIDS deaths in Asia could rise from 440,000 each year currently to nearly 500,000 annually by 2020, and total infections could double from 4.9 million to 10 million.

Our friend Prof Jim Chin, author of the AIDS pandemic: the collision of epidemiology and political correctness, has some stern words about this report on his website.  Prof Chin is particularly aggrieved by the report's claim that "regionally, AIDS is estimated to be the single largest cause of death and morbidity due to disease for adults age 15-44 years."  In reality, in Asia, AIDS wasn't even in the top 10 killers in 2001.

By the way, Prof Chin is discussing his new CFD paper at a lunchtime event on 22nd May in Geneva. Please email if you want more information.

Irresponsible ARV roll-out may undermine scientific breakthoughs

The Times of London has a good leading article on the approval in Britain of the new AIDS therapy Isentress, which it describes as a 'triumph of human ingenuity'.

The arrival of this new drug is indeed miraculous when considered against an increasingly burdensome drug regulatory environment, and the escalating political risks of investing private capital in AIDS research.

The column lets itself down, though, by reflexively and unfairly laying into the South African government's track record on AIDS treatment.  In early 2007, 140,000 of 983,000 eligible South African patients were receiving antiretroviral treatment — the highest number in the developing world. This number is increasing.

South Africa has attracted controversy because its AIDS treatment programme has not moved as quickly as AIDS activists would have liked (in addition to the health minister’s peculiar comments about beetroot).  However, it has always emphasised proper monitoring of patients and the use of certified drugs.  This certainly takes a while to put in place, but leaves SA well-placed to tackle its AIDS problem.

If African governments roll out treatment before infrastructure is ready, more patients will become resistant to existing drugs, leading to higher treatment costs and more premature deaths.  AIDS treatment programmes need to be rolled out slowly and responsibly, allowing time for the necessary infrastructure to be put into place. 

To blunder into an African country with no health infrastructure and promote an ultra-rapid roll out of treatment, as WHO has advocated in the past, risks quickly destroying the effectiveness of new drugs like Isentress.

That is a betrayal of patients, and a betrayal of the researchers whose hard work has brought us these miracle drugs.

XVI International AIDS Conference

The Campaign for Fighting Diseases will be covering the issues surrounding the XVI International AIDS Conference in Toronto (August 13-18).  This blog will be used as a forum to raise relevant issues and encourage a balanced debate.

We invite you to contribute to the discussion!

Rockstar doctors

Tomorrow, Bono (with Alicia Keys) will release a re-recording of the 1986 hit "Don't Give Up" on iTunes in order to help raise funds for a charity providing free AIDS medicines to Africans.

Given the dilapidated health-care infrastructure in many parts of Africa, it makes some sense for charities to deliver and administer treatment for illness and diseases in resource-poor settings.  Indeed, the Rotary Club has been successful in all but eliminating Polio by spearheading and managing vaccination programmes where public health ministries have failed.

But the African healthcare crisis is about more than delivering AIDS medicines. It has far deeper roots.

Without the economic conditions to create wealth in the first place, millions of people living in absolute poverty will die needlessly, and not just of headline grabbing diseases like AIDS, but from diarrhoea and respiratory infections.  These two claim the lives of 15,000 Africans a day - far more than HIV/AIDS.

Admittedly, singing about aids drugs is slightly sexier than clean water and good nutrition and all of the other (seemingly unnoticed) things that came to more prosperous countries long ago.  But these things are still far away from the vast majority of those who live in absolute poverty.

If Bono, and others like Annie Lennox, actually wanted to make a serious contribution to the lives of these millions, they could start by pointing out the real reasons why Africa is poor: the repressive regimes that restrict economic freedoms.  Without them, people will be hard pushed to afford clean water and hygienic living conditions - which are absolutely fundamental to good health. 

Until we get the basics right, there's no chance of ever being spared Bono's philanthropic warbling - or even that of his great grandchildren.

AIDS: a disease of oppression

I was on the BBC World Service last night, making the case that HIV/AIDS can be characterised as a "disease of oppression".

Firstly, political oppression makes it difficult to get the prevention message out, which is absolutely fundamental to stopping the spread of the disease.

Look at what happened in Thailand in 2003, for example: the government decided to crack down on drug users, imprisoning thousands and killing others. Since then, infection rates have soared among drug users.

Economic oppression stops people from creating the kind of prosperity that has left the west largely insulated from the disease. Many governments of poor countries restrict the ability of people to trade freely or set up businesses, resulting in poverty and unemployment. In these situations, drug abuse and prostitution are rife.

Furthermore, counterproductive government policies - such as restrictive planning laws and a lack of land title - are directly responsible for slums, which are highly conducive to the spread of HIV/AIDS.

These are all things that could be countered with government policies that empower people to engage freely in economic activity, rather than preventing them from doing so - which is far too often the case.

I expand on these points in an article I recently had published in, among other places, China's Standard.

Let's have a change of strategy on AIDS

Richard Holbrooke, the head on the Global Business Coalition on HIV/AIDS, is right on the money in this Washington Post column to mark World AIDS day on the 1st December.  He argues that the current strategy is failing to reverse the spread of the disease:

We are not winning the war on AIDS, and our current strategies are not working. Every year since the first World AIDS Day, the number of people affected has increased. The very best that can be said is that we are losing at a slightly slower rate.

Holbrooke argues that the current strategy - which puts its greatest emphasis on treatment - is  a recipe for long-term, expensive failure, because the numbers of sufferers will continue to rise. And once someone starts ARV treatment, they have to remain on it for the rest of their lives.

Holbrooke is quite right to say that the only way to defeat AIDS is to place more emphasis on prevention. And to do that properly, the world health community needs to give more attention to testing and detection. 

It's good to see that even insiders at the highest levels of the health community are beginning to demand a change of course from the UN on AIDS policy.

Let's see if those in command will begin to take their cue from sensible, evidenced-based suggestions like this, or if they will continue to have their agendas dictated by the activists.

"3 by 5": a setback in the fight against AIDS

The Economist has a measured piece on the WHO's "3 by 5" programme, and how all references to it seem to have been 'airbrushed' from the latest UNAIDS report. The article correctly notes that the original target of putting 3 million people onto ARV treatment by the end of this year is going to be missed by some way. But:

The reason for worrying about all this is not that the target was missed, but that the feasibility of reaching it was based on a set of over optimistic modelling assumptions about such things as the effectiveness of drug distribution networks and the competence of local health services.

This is a sound analysis. But in the rest of the article, I think the scribes over at The Economist are letting the WHO off a bit too easily.

The "3 by 5" programme is indeed failing, but its prioritisation of treatment over prevention has done real damage. As a result of this misguided strategy, we get the kind of terrible figures presented in the UNAIDS report - for example, that 2005 saw the highest rate of new infections since the disease was first identified.  The WHO's flagship AIDS programme, it seems, has failed to reverse the spread of the disease and may even be responsible for worsening it.

I'll be writing more on this topic next week, to coincide with World AIDS day on the 1st December, so check back on the blog then.

LIES, AIDS FIGURES AND STATISTICS

Statistics do not lie: people do, helped by casual ignorance. A good example is the United Nations’ mysterious figures for Uganda’s success against AIDS.

The UN and Uganda claim that the prevalence of HIV/AIDS infection in Uganda has fallen from 15% to 5% (or from 30% to 7%, according to Foreign Minister Sam Kutesa on 15 September 2005), which sounds great until you remember that there is no cure for HIV/AIDS: you can reduce the number of new infections but the only way the number of existing victims can fall is if they die.

To increase the confusion, the aid industry mixes up the terms “rate” and “level”: rate means the amount of increase in a given time whereas level means how many people have it at a given time.

If the rate of infection in Uganda were 5% and this really meant that five new people out of a hundred get the virus every year, the number of people infected would double every 15 years (that is the magic of compound interest at work). If, however, the level were 5%, meaning that five people out of a hundred are HIV-positive, this might sound more reassuring but we still do not know what the rate of (new) infection is now. More worryingly, we do not know what happened to all those other people who made up 15% of the population ten years ago.

For the percentage level of HIV/AIDS victims to fall, they either have to die or the population has to increase a lot or a bit of both.

Doing the calculations confirms that death is the secret of Uganda’s success:

• the population of Uganda rose from 17.4 million in 1990 to 23.5 million in 2000, an increase of 35%, according to World Bank figures;

• if the number of people with HIV (the level) made up 15% of the population in 1990 (2.61 million people) and had remained the same in 2000, that same number would then make up only 11% of the population;

• the current official HIV+ level is about half that: this implies that either half the HIV+ victims have died and that there were no new infections, or, realistically, that much more than half the victims have died and there were also new infections.

The good news, however, is that there are separate indications that the new infection rate may be falling: national estimates are unreliable but a count of infected pregnant women in hospitals in Kampala in 2004 did show a drop of two-thirds over the previous ten years, indicating that the rate of new infection had fallen. On the other hand, a random test of 700 children tested in war-torn Gulu province in September 2005 showed 300 were HIV+, district hospital spokesman Dr. Geoffery Openythoo told reporters.

Similar statistical obscurantism applies throughout Africa, concealing and distorting the real impact of this plague.