Fight against Aids: How UNAids perpetuated the myth of condom effectiveness in Africa in the face of all the evidence

The recent appointment of Michael Sidibe of Mali as the new Director of The Joint United Nations Programme on HIV/AIDS (UNAIDS), the main advocacy body in the global fight against HIV, the deadly virus that causes AIDS, might mark a significant turning point in the way the organization handles its mandate in the political and scientific spheres of the deadly disease.

However, two recent books criticizing the way the organization is putting political correctness above scientific evidence as well as recent calls in some quarters for the organization to be disbanded altogether has thrown the usefulness the global body into serious question.

Experts now know that unprotected sex involving high rates of long-term concurrent sexual relationships coupled with low rates of male circumcision has led to national prevalence rates in East and Southern Africa ranging from 6 percent to 24 percent, according to the 2007 report: “WHY IS HIV PREVALENCE SO SEVERE IN SOUTHERN AFRICA?: The role of multiple concurrent partnerships and lack of male circumcision”, written by Daniel T. Halperin of the Department of Population and International Health Harvard School of Public Health and AIDS expert and author Helen Epstein.

However, UNAIDS and other AIDS organizations fail to recognize fully the role of long-term multiple concurrent relationships in the spread of HIV and instead appear to favour the use of condoms, abstinence and other less effective methods.

Take the case of Dr. Norman Hearst, an epidemiologist at the University of California, San Francisco.

In 2003 Dr. Hearst and his research assistant Sanny Chen, then of San Francisco’s Department of Public Health, carried out an extensive literature review commissioned by UNAIDS on the effectiveness of condoms in preventing the spread of HIV virus in sub-Saharan Africa and other developing regions.

The initial report titled: “CONDOMS FOR AIDS PREVENTION IN THE DEVELOPING WORLD: A review of the scientific literature”, concluded that although condoms were about 80% to 90 percent effective as a public health strategy in halting the spread of AIDS in some concentrated epidemics (epidemics affecting Men who have Sex with Men, Injecting Drug Users and Commercial Sex Workers) in places like Thailand and Cambodia, condoms were seen as ineffective in preventing the spread of HIV/AIDS in generalized epidemics like those taking place in eastern and southern Africa.

“These findings surprised us and were not what UNAIDS wanted to hear at all”, recalls Dr. Hearst who says that his report provoked serious debate within UNAIDS.

Efforts were made by UNAIDS to edit the Hearst/Chen report into something that might be more politically palatable to the organization.

In fact, Dr. Hearst was shown various drafts of the heavily edited document, which UNAIDS was expected to publish but in the end never did.

“Instead they released their own separate statement about how wonderful and effective condoms are. This did not have our names on it, nor would I have wanted it to,” says Hearst. “It made no reference to our review or our report. I was never given any explanation for this decision.”

But the conclusions reached by the Hearst/Chen study would have been of major importance to policy makers in Africa, the West and elsewhere in the developing world; AIDS agencies; AIDS activists; and the general public at large in terms of policies formulation and program implementation to combat the spread of AIDS.

However, this crucial report was not made public by UNAIDS.

According to UNAIDS insiders, the organization rewrote the entire report-even removing the names of the researchers and published something quite different from what they had submitted.

Taken aback by this blatant action, Hearst and Chen published their original findings in 2004 in Studies in Family Planning, a major peer-review journal.

“It is true that the way that UNAIDS dealt with my report says a lot about the culture of UNAIDS and how they operate -- and that much of what it says is not very good,” laments Dr. Hearst. “On the other hand, I have refrained until now from trying to make this a bigger issue than it should be. And I don't have a great desire to participate in any unnecessary UNAIDS bashing.

Prior to the commissioning of the UNAIDS condom review study, Norman Hearst had actively participated in the organization’s affairs spanning the course of several years.

But since that time he feels that he has been blacklisted by UNAIDS.

“I have never been asked to consult for them, be on any of their committees, participate in any UNAIDS meetings, etc., despite having done all of these things previously.” says Hearst.

In fact, some UNAIDS officials are said to have denied they had ever funded the study. “I don't know if these individuals were misinformed or deliberately lying.”

But the Hearst-Chen episode is not the only instance where the unexpected results a commissioned report on the ineffectiveness of condoms in stopping the spread of HIV in generalized epidemics in sub-Saharan Africa has been hidden from the general public or simply blatantly ignored.

The findings of other independent consultants have also reported to UNAIDS that partner reduction, and not condoms, abstinence and the like have been the key in turning back the HIV/AIDS juggernaut-as what happened in Uganda during the early years of the plague.

Another illustration of UNAIDS early intransigence (as well as that of its predecessor, the WHO’s Global Program on AIDS) about the effectiveness of behaviour change, is the case of the landmark study led by Dr. Maxine Ankrah, an African-American sociologist, who was at the time the head of the department of Social Work and Social Administration at Makerere University, Kampala. Ankrah’s pioneering study on sexual behaviour in Uganda in 1989 (part of a WHO Global Program on AIDS study on the types of sexual behaviours that promotes the spread of HIV/AIDS) led to the publication of “AIDS IN UGANDA: analysis of the social dimensions of the epidemic, National Survey, September-December 1989”.

Maxine Ankrah’s study was one of a pair showing that partner reduction, not condoms, was the main reason for Uganda's HIV decline.

A second study of sexual behaviour in Uganda was carried out in 1995, by which time the HIV rate in the country had fallen significantly.

When Ankrah’s findings were compared to the 1995 follow-up, it was clear that the HIV decline correlated strongly with a decline in multiple sexual partnerships.

However, for years various UNAIDS reports maintained that condoms, not partner reduction had been the major reason for Uganda’s success against AIDS.

Ankrah’s study, showing much higher rates of casual sex in 1989 compared to 1995 was never made public or referred to in UNAIDS or WHO documents.

Other studies suggesting partner reduction had been more important than condoms in reducing Uganda’s HIV infection rate were also shelved; these include Tom Barton’s unpublished report, which was also commissioned by UNAIDS and also never made public, “Epidemics and Behaviours”; Making condoms work for HIV prevention,” which is part of UNAIDS’ unpublished Best Practice Collection as well as a Uganda Ministry of Health’s reports on he 1995 Demographic and Health Survey.

Subsequently, other researchers showed that patterns of sexual partnerships in Uganda were complex, as they would turn out to be in other East and Southern African countries.

Unlike people in Western countries, who mainly practice a combination of casual sex and “serial monogamy”, people in sub-Saharan Africa are somewhat more likely to have a small number of long term relationships at the same time.

These so-called “concurrent partnerships” turn out to be much more dangerous than “serial monogamy” even if most people have relatively few sexual partners.

Many experts now maintain that this could help explain why HIV rates are so high in Africa, and why condoms—which are seldom used in long term relationships, even concurrent ones—have not been more successful in bringing the epidemic under control.

Maxine Ankrah ‘study was not only ignored, but her data was “re-analyzed” so that it would support the hypothesis that condoms had brought HIV under control in Uganda.

Three independent researchers have since shown that Ankrah's original analysis was correct. Various subsequent studies have also proven the Hearst/Chen report to have been accurate.

Why would UNAIDS, a renowned global organization dedicated to educating governments around the world about the greatest plague of our times, behave in such a manner unbecoming of a world institution?

Critics of the organization believe that the facts unearthed by Maxine Ankrah, Norman Hearst, Tom Barton and others were simply too hard for UNAIDS to swallow since they contradicted the organization’s belief system- that condoms and not behaviour change are the ultimate solution to preventing the spread of the pandemic in sub-Saharan Africa and other developing regions. In short, it was a clear case of ideology taking precedence over epidemiological facts.

“Top brass at UNAIDS have admitted to me privately that they knew in the 1990s that in Africa, long term concurrent relationships were more dangerous than casual/commercial ones,” laments Helen Epstein, speaking from her home in Harlem, New York and author of the recent book THE INVISIBLE CURE: Africa, the West and the fight against AIDS .

“I asked them why nothing was done to raise awareness about it, and received no reply…. This [research on and educational programs geared towards long-term, multiple concurrency] all could have happened ten years ago, had Western AIDS experts shared the information, which some independent academics were urging them to do. Would it have made a difference for HIV prevention? We may never know, but according to the charter of the World Health Organization, access to accurate health information is a human right.”

UNAIDS has repeatedly emphasized to the world that declines of HIV-infection rates in Thailand, for example, was attributed to the use of condoms only.

However, it was condoms (for high risk groups) plus a reduction in multiple sexual partnerships according to two earlier reports published in 1996 and 1998 respectively: “Changes in sexual behaviour and a decline in HIV infection among young men in Thailand” by K.E. Nelson and colleagues in the New England Journal of Medicine, 1996; and “AIDS and behavioural change to reduce risk: a review” by M.H. Becker and J.G. Joseph in the American Journal of Public Health.

Critics of UNAIDS have concluded that the main reason why it, and other international bodies ignore behaviour change is that primary prevention of any infectious diseases is perhaps the greatest health challenge of our time.

Getting human beings to change deeply ingrained behaviour (sexual or otherwise) is a monumental task if there ever was one.

Historically the prevention and control of diseases linked to human behaviours, such as sexually transmitted diseases (STD), has been largely unsuccessful.

For example, doctors dealing with the spread of STDs were aptly skilled in diagnosis and treatment but were inept at eliminating or reducing what is called sexual risk behaviour.

But its not only sexual behaviour but human behaviour such as cigarette smoking or adopting a healthy diet and exercise.

Such behavioural changes don’t come over night and might take decades and even generations to adopt.

Behaviour change has also been overlooked because there is a certain degree of taboo exists around the subjects such as sexually promiscuity, illegal drug use and prostitution particularly when dealing with relatively conservative African societies.

Officials responsible for prevention programs and policy formation chose not to deal with these behavioural aspects of HIV/AIDS prevention for the simple reason that illegal drug use and sexually promiscuity have moral connotations attached to them.

Furthermore, if one is talking about sexual promiscuity and sub-Saharan Africa there is an added risk of re-enforcing the widely held racial stereotype of the over-sexed African; something that these learned Western-educated men and women would rather have avoided least they be branded as racist.

“Most AIDS programs are more comfortable trying to cope with the medical and scientific aspects of HIV/AIDS rather than its social and behavioural aspects,” says Dr. James Chin, a professor of epidemiology at the School of Public Health, University of California at Berkeley and author of he recent book The AIDS Pandemic: the collision of epidemiology with political correctness.

Another bone of contention Chin and other critics of UNAIDS have is the organization’s belief that poverty causes HIV/AIDS; that the AIDS pandemic in Africa and elsewhere in the developing and developed world is fuelled or driven by poverty and discrimination.

Or, to be more precise, that situations of poverty lead to behaviours that are more conducive to the spread of HIV.

For example, poor women in sub-Saharan, and elsewhere in the developed and developing world turn to commercial sex work, putting themselves and their clients at risk, risk that would not exist if such women had not to resort to sex work.

Furthermore, proponents of the poverty-leading-to-AIDS argument say that poverty causes poor nutrition, which weakens immune systems making people more susceptible to HIV infection in the first place.

This belief is highly controversial and has had devastating repercussions for Africa!

“This litany used by UNAIDS and most AIDS programs is socially and politically correct but there are no epidemiological data to support this myth or misconception about HIV transmission,” says Chin. “Poverty is a socially and politically attractive hypothesis to account for high HIV prevalence, but available data support the opposite”.

The data Chin refers to points to the conclusion that poverty and discrimination do not play an obvious role in HIV prevalence (the proportion of people in a given population who are HIV positive at a given time).

For example, the wealthiest countries in sub-Saharan Africa have the highest HIV prevalence rates.

The southern African countries of Botswana, South Africa and Swaziland, for instance, have the highest HIV infection rates on the African continent between 25-40 percent.

Meanwhile, some of the poorest countries such as Somalia, Guinea, Liberia, Mali and Eritrea have among the lowest rates of fewer than 3 percent.

Further, another curious link is that persons in the top 20 percentile for income in Kenya, Tanzania, and Ethiopia have HIV infection rates several times higher compared to persons in the lowest 20 percentile.

UNAIDS official response to some of Dr. Chin’s accusations deal mainly with what Chin sees as UNAIDS’ flawed estimation and projection of HIV infections and AIDS cases and deaths (In 2004, for example, UNAIDS discovered a mistake in the analysis of antenatal surveillance data that led to an overestimation of HIV in some rural areas of Africa.

Since the majority of sub-Saharan Africans since live in the rural areas, this led to a downward revision of the UNAIDS prevalence estimates in many countries by 25 to 40 percent) and the prediction (which so far has yet to fully materialize) that there will be an explosion of HIV infections in Asia.

However, the rebuke fails to address UNAIDS’ shortcomings in dealing with the behavioural and social aspects that drive the HIV/AIDS pandemic in developing countries.

But this issue of proclaiming that poverty (or wealth) is causing HIV/AIDS is too simplistic.

Dr. Justin Parkhurst, a lecturer in health policy at the London School of Hygiene and Tropical Medicine believes that those who talk of HIV being caused by poverty are asking the wrong question.

“To me, what we really need to be asking is - what is it about given levels of income, in particular contexts, that are linked to risk behaviour for HIV?”

Parkhurst speculates that is sub-Saharan Africa, while poverty has been linked to particular risk situations - such as reliance on transactional sex, or lack of information about HIV - it may also limit individuals’ mobility and thus limit them to smaller social and sexual networks.

Conversely, individuals with higher incomes would tend to be more mobile and with more social and sexual networks, behaviour that has been linked with the spread of the deadly HIV virus.

Parkhurst also believes that affluence would also be linked to the ability to pay for sex, or to provide some kind of support/assistance for sex (transactional sex, not purely commercial sex). However, he believes that this is context specific.

Available data from Demographic and Health Surveys, which exists for over a dozen African countries and looks at the correlation between wealth and HIV incidence strongly suggests that there is indeed a relationship between increasing HIV prevalence with increasing wealth.

However, this trend is by no means universal, and at times men and women show different patterns.

For example, the southern African country of Swaziland shows a relatively non-existent relationship between wealth and HIV incidence; with seeming impact of wealth on prevalence-in women the wealthiest group has slightly lower prevalence than other income groups.

In Lesotho, men in the middle income bracket have the highest prevalence, while the country’s wealthiest women have a slightly lower prevalence rate than other women. This again reinforces Parkhurst’s notion that the link between wealth/poverty and HIV infection is context specific.

There are also cases where the link between education (an indicator of wealth) and HIV infection appear to change over time.

One study conducted by James R. Hargreaves of the London School of Hygiene and Tropical Medicine and colleagues have documented such a change.

In early years of the epidemic it was seen that higher educated people had higher HIV rates, which was perhaps linked to wealth and mobility.

However, this seems to change over time where it becomes more protective as epidemics mature, and where the educated know more and are more likely to protect themselves from he deadly virus. Justin Parkhurst speculates that this process could also be observed with income.

According to experts the relationship between wealth and HIV prevalence is changing over time.

James Hargreaves of the London School of Hygiene and Tropical Medicine and his colleagues conducted a systematic review of some 4000 abstracts and 1200 papers published peer reviewed articles, which compared individually, measured educational attainment and HIV status among at least 300 individuals representative of the general population of countries or regions of sub-Saharan Africa.

Thirty-six articles were included in the study, containing data on 72 discrete populations from 11 countries between 1987 and 2003, representing over 200,000 individuals.

What these researchers discovered was that studies on data collected prior to 1996 generally found either no association or the highest risk of HIV infection among the most educated.

Furthermore, studies conducted from 1996 onwards were more likely to find a lower risk of HIV infection among the most educated.

Where data over time were available, HIV prevalence fell more consistently among highly educated groups than among less educated groups, in whom HIV prevalence sometimes rose while overall population prevalence was falling.

In several populations, associations suggesting greater HIV risk in the more educated at earlier time points were replaced by weaker associations later.

Therefore, HIV infections appear to be shifting towards higher prevalence among the least educated in sub-Saharan Africa, reversing previous patterns.

Critics of UNAIDS says that it's worth remembering that UNAIDS is an advocacy and not a scientific body and that they should not be looked to for scientific answers or evidence.

Critics are quick to point out that UNAIDS is driven by politics, fund-raising and Western ideology, and not the empirical evidence.

However, its ideology is not shared by the majority of the countries where UNAIDS works.

This maybe a problem of development since many large AIDS organizations as well as prominent donor organizations are indeed ideology-driven says Edward C. Green of the Department of Population and International Health, Harvard School of Public Health whose next book will focus on AIDS and ideology.

In her recent paper, AIDS and the Irrational, published in the November 2008 issue of the British Medical Journal, Helen Epstein says that the problem with UNAIDS is its duel and duelling mandate, which on the one hand is to dispense accurate scientific information about the HIV/AIDS pandemic, and on t/he other hand to advise governments around the world on how to deal with the deadly disease.

“The intrinsic tension between politics and science has been especially acute when it comes to answering two of the most vital questions in AIDS prevention: why is the epidemic in Africa so severe? And what are the best ways of dealing with it?” says Epstein.

She recommends that scientific issues should be addressed through a more open process of research and peer review, rather than by the fiat of a single, largely unregulated UN agency.

Surprisingly, there is a considerable lack of formal education about LMCP in school-based AIDS education programs in SSA given that fact that knowledge of LMCP as a driving factor of the epidemic in Africa has been available since Maxine Ankrah’s report in 1993.

Instead such programs advocate abstinence, condoms, etc.

Experts such as Helen Epstein says that education about concurrency should be integrated into all AIDS programs in Africa including those aimed at school children and young people.

Epstein also stresses that education should stress that although delay of sexual debut is a sensible goal, personal fidelity is no guarantee of protection against HIV if the partner one eventually ends up with has even one other concurrent partners.