UNAids and myth of condoms efficacy against Aids

Saturday February 7 2009

By CURTIS ABRAHAM

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

However, two recent books criticising the way the organisation is putting political correctness above scientific evidence as well as recent calls in some quarters for the organisation to be disbanded altogether have thrown the usefulness of 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 six per cent to 24 per cent, 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 at the Harvard School of Public Health and Aids expert and author Helen Epstein.

However, UNAids and other Aids organisations fail to recognise 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 per cent to 90 per cent 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 generalised 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 organisation. 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 programme implementation to combat the spread of Aids.

However, this crucial report was not made public by UNAids. According to UNAids insiders, the organisation 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 organisation’s affairs spanning the course of several years. But since that time he feels that he has been blacklisted by UNAids.

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,” he said.

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

Critics of the organisation believe that the facts unearthed by Norman Hearst and others were simply too hard for UNAids to swallow since they contradicted the organisation’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. Epstein is the 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 programmes geared towards long-term, multiple concurrency] could have happened 10 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 Organisation, access to accurate health information is a human right.”

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 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.

This applies not only sexual behaviour but human behaviour such as cigarette smoking or adopting a healthy diet and exercise. Such behavioural changes don’t come overnight and might take decades and even generations to adopt.

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

Officials responsible for prevention programmes and policy formation chose not to deal with these behavioural aspects of HIV/Aids prevention for the simple reason that they have moral connotations attached to them.

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

Most Aids programmes 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 the recent book The Aids Pandemic: The collision of epidemiology with political correctness.

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.

They 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 may be a problem of development since many large Aids organisations as well as prominent donor organisations 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 dual mandate, which on the one hand is to dispense accurate scientific information about the HIV/Aids pandemic, and on the 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 be addressed through a more open process of research and peer review, rather than by the fiat of a single, largely unregulated UN agency.

Experts such as Helen Epstein says that education about concurrency (see story on page 16) should be integrated into all Aids programmes 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.

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 per cent) and the prediction (which so far has yet to fully materialise) 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.

Critics of the organisation 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 organisation’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 programmes geared towards long-term, multiple concurrency] could have happened 10 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 Organisation, access to accurate health information is a human right.”

UNAids has repeatedly emphasised to the world that decline 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.

UNAids has repeatedly emphasised to the world that decline 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.