The Uncontrolled AIDS Epidemic

The Current Epidemic

For the first time since the Black Death in the Middle Ages, a disease is sending whole nations into absolute demographic decline. AIDS was first recognized in the late 1970s. In the years since, some 25 million people have died of the disease.1 Yet the deadly virus continues to spread with horrifying rapidity in many parts of the world, Today, about 42 million people are infected with the AIDS virus worldwide. Millions die each year, yet transmission rates in many of these countries are so startlingly high that the HIV/AIDS epidemic continues to claim millions of new victims. While over 3 million died of HIV/AIDS in 2002, for example, five million more were newly infected that year.2

The chief region affected by the HIV/AIDS crisis is Sub-Saharan Africa. It is home to 70% of the adults infected with the virus, and 80% of the children. In the Republic of South Africa, for example, over 13% of the total population is infected with the virus.3

AIDS shortens life spans, raises the death rate, and may, in “highly affected” countries, reduce the overall population. By 2015, in Africa’s 35 “highly affected” countries, average life expectancy of 48.3 years is projected to be 6.5 years less than it would have been without AIDS. An estimated 42 million people worldwide are currently HIV positive, with most of these residing in Africa and the Caribbean. They will, barring life-extending retroviral treatment, all be dead within a decade. Speaking of Sub-Saharan Africa as a whole, there will be 300 million fewer Africans in 2050 because of deaths from HIV/AIDS.4 Even this number, as large as it is, fails to convey the enormous devastation wrought by AIDS, which leaves millions of broken families and orphans in its wake.

The Wrong Paradigm

The need for effective AIDS relief in Africa, as called for by President Bush, is tragically self-evident. But before we throw $15 billion at the problem, we must understand why past HIV/AIDS programs in Africa have failed. It is not because they lacked resources, but rather because they were based on a false — and deadly — premise of reckless promiscuity among Africans. Many AIDS experts have long maintained that heterosexual transmission and the sexual behavior of Africans account for 90% or more of HIV infections in African adults. But the series of studies by Gisselquist, Potterat, and their colleagues, published in three parts in the March 2003 issue of a respected peer-reviewed journal, the International Journal of STD & AIDS, suggests that the chief culprit may be medical transmission.5

These studies empirically demonstrate that unsafe injections and other medical exposures to contaminated blood may account for two-thirds or more of the new cases of HIV/AIDS. In this new view, heterosexual sex is, at most, responsible for one-third of the spread of HIV in Africa.

The Conventional Wisdom

In the late eighties, influential AIDS experts wrongly concluded that heterosexual sex was playing an exceptional role in the African AIDS epidemic. In a prominent 1988 article in Science, Piot et al wrote that “Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease.”6 That same year the World Health Organization’s (WHO) Global Program on AIDS circulated estimates that 80% of HIV infections in Africa was due to heterosexual transmission, 10.8% was from mother-to-child transmission. 6% from blood transfusions, 1.6% from contaminated medical injections and other health care procedures, and 1.6% from men who have sex with men (MSM) and injection drug use (IDU).7

Once this paradigm was firmly in place, it tended to be self-perpetuating. Epidemiological evidence of medical transmission of AIDS by unsafe injections and other medical exposures to contaminated blood was ignored or misrepresented. The predictable result of this stultification of the scientific process has been the acceptance of heterosexual transmission of AIDS in Africa as fact. The World Health Organization now claims that “current estimates suggest that more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex.”8

But where did the “consensus” come from?

AIDS and Ideology

Very early on in the African epidemic, AIDS was demographically associated with sexually active populations, principally prostitutes and their clients.9 This association seems to have caught the attention of various interest groups which, for diverse ideological, political, and financial reasons, promoted the notion of heterosexual transmission.

First, many in the foreign aid community shared the conviction that Africa was “overpopulated.”10 In order to drive down the birth rate, ongoing population control programs relied upon the promotion and distribution of condoms and contraceptives. Those who supported or participated in these anti-natal programs would be inclined to emphasize the role of sexual transmission in African HIV/AIDS as an additional argument for condom promotion and distribution.

Second, USAID began piggybacking its HIV/AIDS programs onto preexisting family planning programs in 1984. Organizations which applied for funding for such “integrated” programs — so-called because they brought together HIV prevention and pregnancy prevention under the same roof — may have been inclined to emphasize sexual transmission of HIV in their grant proposals and reports. If “unprotected” sex was driving up both the birth rate and the HIV/AIDS rate, then their integrated AIDS/SRH clinics were the answer to both crises.

Third, HIV/AIDS was identified in the Western mind with homosexuals and injection drug users. As Gisselquist et al write, “[I]t was in the interests of AIDS researchers in developed countries — where HIV seem stubbornly confined to MSMs, IDUs, and their partners — to present AIDS in Africa as a heterosexual epidemic.”11

Fourth, as Packard and Epstein have documented, “the role of sexual promiscuity in the spread of AIDS in Africa appears to have evolved out of prior assumptions about the sexuality of Africans.”12 That is to say, Africans were imagined to have too much sex with too many partners in circumstances that were too risky. These assumptions have little basis in reality. As Brewer et al report, “Levels of sexual activity reported in a dozen general population surveys in Africa are comparable to those reported elsewhere, especially in North America and Europe.”13

Fifth, as Gisselquist et al notes, “health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations.”

In short, individuals and organizations read into the African situation their own biases and their own agenda. The result was what Gisselquist et al call the “ignoring and misinterpreting of epidemiologic evidence.”

New Evidence: HIV Transmitted by Unsafe Injections

In their second study, Gisselquist, Potterat and their colleagues examined all the evidence on African AIDS transmission available through 1988, before what they call the “premature closure of the debate.” In all, they reviewed 22 separate studies. What they found is startling:

  • Injections were more highly associated with HIV than sex.14

  • Most of those infected with HIV were in a long-term monogamous relationship. “The consistency of the evidence suggests a large majority of HIV infections in non-promiscuous adults.”15

  • Those of higher socioeconomic status have higher rates of HIV than those of lower status. “Since STD [sexually transmitted disease] have long been associated with lower socioeconomic and educational attainment, it was at least equally plausible that associations between high status and HIV pointed to differences in health care rather than sexual behavior.”16

  • Clinic attendance was associated with HIV.17

  • Infants were medically infected with HIV. “High rates of HIV infections in children that could not reasonably be attributed to vertical [mother-to-child] transmission.”18

Gisselquist et al estimate the actual percentage of HIV/AIDS cases in Africa that was transmitted sexually. The figure they come up with — 25 to 35% — is far below the 90% hypothesis customarily assumed by researchers.19 The risk of infection with HIV from a contaminated medical injection has been estimated at one in 30, which is 33 times higher than the risk from heterosexual sex.20

Where do Africans experience such exposures, which take such a toll on African life? To answer this question, we must take a close look at existing HIV/AIDS and family planning programs, and the relationship between the two.

Ineffective Methods of Prevention

Deadly Combination The belief that HIV/AIDS in Africa was sexually transmitted led directly to the current approach to HIV/AIDS relief, as practiced by the United States Agency for International Development, the United Nations Global Fund, and other national and international agencies. This is the so-called ‘“integrated” approach, which piggybacks HIV/AIDS programs on existing “sexual and reproductive health” (SRH) programs.

The USAID has been promoting the integrated AIDS/SRH approach since 1984, when the numbers of those infected with HIV in Sub-Saharan Africa could still be counted in thousands, rather than millions. In the years since, USAID reports that it has spent over $2.3 billion in its “fight against the global AIDS pandemic.”21 The lion’s share of this money has gone to Africa, and into integrated programs.

Integrated AIDS/SRH programs are thus the “gold standard” in HIV prevention. Family planning NGOs hoping to be on the receiving end of a USAID grant are well-advised to adopt this paradigm and to testify to its effectiveness. So we find Population Action International (PAI), a USAID-funded population control group, averring that “Preventive measures such as sexual health education and provision of condoms that provide dual protection from both sexually transmitted infections (STIs) and unwanted pregnancies remain the most effective and affordable interventions for slowing the HIV pandemic [italics added].”22

Neither the international consensus on the importance of integrated AIDS/SRH programs, nor the billions of dollars poured into these programs, has checked the spread of the disease. On the contrary, the number of HIV cases in Sub-Saharan Africa has continued to rise exponentially. Since USAID began its integrated programs, the number of people infected with HIV/AIDS globally has increased from 43,000 in 1987, to over 14 million by 1995, to a total of about 60 million today, with an increasing percentage of these cases in Sub-Saharan Africa.23 And the virus continues to infect record numbers each year.

Most HIV/AIDS cases on that continent are not the result of sexual contact at all. Rather they are the result of contact with the HIV virus through dirty needles and other substandard, invasive medical procedures. More to the point, they are the result of the kinds of procedures — Depo-Provera and other injections, Norplant insertions, IUD implantations, tubal ligations, and MVA abortions — that are a staple of AIDS/SRH clinics. The implications of this are sobering: Could the very programs undertaken to stem the HIV/AIDS pandemic be contributing to its spread?

The first thing that must be said about integrated projects is that they bring both seropositive (HIV positive) and seronegative (HIV negative) patients into the same clinic, and subject both to the same kinds of invasive medical procedures. The possibility of transmission by contaminated instruments in such a setting is obviously an ever-present danger, and one that can only be averted by taking the strictest care. Substandard medical practices are not uncommon in Africa’s chronically under-funded, understaffed, and poorly equipped clinics, conditions which the single-minded focus of foreign aid donors on family planning has done little to alleviate.

This is not mere speculation. There is empirical evidence linking HIV/AIDS transmission directly to African clinics that provide sexual and reproductive health care. In two STD clinics in Rwanda, HIV prevalence in attendees was four to nine times higher than in general population samples. Among STD outpatients in Zambia in 1985, HIV prevalence in those reporting previous attendance at an STD clinic was 37% compared to 23% for first-time attendees. Among men attending an STD clinic in Nairobi in 1986–87 after recent contact with prostitute women, 8% seroconverted within an average of 15 weeks of follow-up.24

Brewer et al found an increased risk of HIV infection among women who received reproductive health care at African clinics. As they write: “A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counterparts.”25 In others words, clinic attendance seems to have condemned some mothers to untimely deaths.

The Victimization of Women

An examination of HIV/AIDS statistics by region and by gender reveals a curious anomaly. In areas of the world where the primary means of transmission is assumed to be heterosexual sex, such as Sub-Saharan Africa, North Africa and the Middle East, and the Caribbean, the majority of HIV-positive adults are women. The United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization report that, in Sub-Saharan Africa, 58% of those who have HIV/AIDS are women.26 In the younger age groups the disparity is even higher: “[O]verall about twice as many young women as men are infected in Sub-Saharan Africa.”27

These results are surprising because they appear to contradict what we know about human sexual behavior. Cross culturally, men are more promiscuous than women. Moreover, some of their numbers patronize prostitutes. These are behaviors which expose men to a greater risk of sexually contracting HIV/AIDS.

“Why do young African women appear so prone to HIV infection?” asks UNAIDS and WHO. Their answer (which assumes that HIV is sexually transmitted) is that African women are forced by circumstances to have sex with HIV positive men: “The combination of dependence and subordination can make it very difficult for girls and women to demand safer sex (even from their husbands) or to end relationships that carry the threat of infection.”

This explanation — that African women are infected by rapacious men — may be convincing to the radical feminist mind, but it completely begs the question. Why does HIV in Africa disproportionately strike women?

The answer lies in the medical transmission of HIV/AIDS. The public health sector in many African countries has simply collapsed. African clinics are short of almost everything, from vaccines and malaria tablets to rubber gloves and needles. Little, if any, care is available to African men and women ill with tropical diseases. Medical equipment, such as syringes, surgical instruments, and manual vacuum aspirators, cannot be properly disinfected before being reused. The local blood supply is unreliable.

The one exception to the generally dismal state of primary health care in Africa is Western-funded sexual and reproductive health programs which target women, African medical workers are taught (and paid) to emphasize reproductive health procedures, often to the near exclusion of primary health care. Otherwise poorly equipped clinics are kept well-stocked with Depo-Provera, IUDs, and condoms.

Is it mere coincidence that the same groups that are targeted for invasive procedures are disproportionately afflicted with AIDS? We think not. Women and girls account for such a high percentage of HIV/AIDS victims in Africa because they are infected during procedures designed to disable their reproductive systems and prevent them from conceiving or bearing children.

Dirty Needles and Tainted Vials

Among the sexual and reproductive health procedures that may have directly contributed to the spread of HIV/AIDS among women in Africa are the reuse of injection equipment and multidose vials of injectable contraceptives such as Depo-Provera, or other medications used for STD treatment and ante-natal care. The likelihood that needles and syringes will be reused is high. Many of these clinics are filthy and drug use is largely unregulated.

The World Health Organization has long recognized that disposable syringes — an all-plastic syringe with a separate steel needle — are not thrown away in the developing world, but reused again and again, with all the risks that this entails.28 Warns the WHO: “Reuse of syringes and needles in the absence of sterilization exposes millions of people to infection. Syringes and needles are often just rinsed in a pot of tepid water between injections. In some countries the proportion of injections given with syringes or needles reused without sterilization is as high as 70%.”29 Elsewhere, the WHO speculates that, in Sub-Saharan Africa and Asia, half of all syringes and needles on these continents are reused.30

This estimate of 50% reuse for syringes and needles seems unrealistically low, for two reasons. First, as anyone who has been in an African clinic can testify, practically every kind of medical device is in short supply. It is highly unlikely that under-trained personnel would throw away a perfectly serviceable needle and syringe. Even if they did, these disposable syringes and needles are unlikely to actually find their way into a landfill. WHO admits that “In developing countries, additional hazards occur from scavenging on waste disposal sites and manual sorting of the waste recuperated at the back doors of healthcare establishments.”31 Those syringes and needles recovered from the trash are then sold on the black market to untrained lay practitioners who reuse them.32 The percentage of needles and syringes that are reused is likely closer to 100% than to 50%.

The sheer magnitude of the number of injections given suggests that each syringe and needle is not only reused, but that it is reused until it is literally “worn out,” that is, until the plunger no longer seals against the inside of the syringe or the needle breaks off.

Where does the limited supply of needles and syringes come from? In part from the injectable contraceptives, chiefly Depo-Provera, which are a staple of family planning programs.

From 1994–2000, USAID provided 41,967,200 units of Depo-Provera into the developing world, at a cost of over $40 million.33 But even this number pales in comparison to shipments by the United Nations Population Fund (UNFPA), which boasts of being the largest supplier of contraceptives in the world. The UNFPA provided about 12 million doses in 1992 and 20 million doses in 1994, including shipments for the World Bank.34

Depo-Provera is a major component of foreign-funded family planning programs in Africa. Although exact numbers are difficult to come by, the UNFPA spends more money on its African programs than in any other single region. USAID sends more units of Depo-Provera to Africa, to countries such as Mozambique, Tanzania and Nigeria, than to any other part of the world.

According to Dr. Jim Shelton, who has served as USAID’s senior reproductive health advisor since 1977, the U.S. aid agency has only shipped single-dose vials from the inception of its Depo-Provera program.35 It is unclear whether the UNFPA, International Planned Parenthood Federation (IPPF), or other suppliers also ship only single-dose vials, with an equal number of syringes and needles, or whether they provide the drug to end-users as multi-dose vials, with the associated risk of contamination and HIV transmission that this entails.36

USAID-supplied vials come in packages which contain, in the words of the accompanying advertising poster, “complete injection kit for convenience.” An injection kit is a plastic syringe equipped with a steel needle. Both of these devices are reusable and are, in the impoverished African context, probably reused hundreds of times.

In Kenya, PRI investigators recently discovered that Depo-Provera kits are available over-the-counter at a nominal price from dilapidated “pharmacies” for private use in completely unsupervised settings. These kits were advertised as having been “Manufactured in Belgium by Pharmacia and Upjohn, and distributed by PSI Kenya.” PSI stands for Population Services International, one of the principal recipients of USAID family planning/population stabilization funds. Encouraging the self-injection of drugs which, in the United States, can only be administered by a health care professional, raises additional questions. A number of serious warnings are listed by the manufacturer including “delay in spontaneous abortion,” “fetal abnormalities,” blood clots, “a sudden partial or complete loss of vision.” No reference is made to these dangers in the standard “bilingual patient information leaflet.” The “leaflet” — a single 3½” by 8” sheet — answers the question, “Is Megastron [another brand name for Depo-Provera] Safe?” by saying only: “Yes, it is safe for use. Severe side effects, like heavy bleeding, are unusual. Some women may experience missing periods or spotting, but there is no need for undue concern.” No mention here of birth defects, blood clots, or blindness.

Taking Depo-Provera while not under a doctor’s care renders women vulnerable to these potentially deadly or disabling side effects. To the extent that follow-up care is received, and involves injections, then these women are put at additional risk of exposure to HIV.

And where do the millions of needles and syringes distributed to the general public wind up? It is safe to assume that virtually all of these “disposable” syringes and needles remain in circulation long after they have been initially used.

How many Depo-Provera “injection kits” have been shipped to Sub-Saharan Africa over the past decade from all sources? It is probably safe to assume that more than 100 million Depo-Provera syringes and needles have been put into circulation in Africa since the early nineties.37 During this same decade, something like 40 billion injections have been given to Africans. And the AIDS epidemic simply exploded.

In the past few months, in a belated recognition of the possible role played by tainted needles and syringes in the transmission of AIDS, USAID has modified the injection kits. The first change came late last year and involves the replacement of the previous reusable syringe with an “auto-disable syringe.” The plunger on this type of syringe can only be pulled back once. Once the plunger is depressed, the plunger cannot be withdrawn a second time. The second change, which was just accomplished in May 2003, was the replacement of the standard needle size with a needle size unique to the Depo-Provera syringe, which cannot be attached to any other syringe. These changes constitute a tacit admission of the dangers of providing reusable injection equipment in circumstances where poverty and over-the-counter distribution makes their reuse virtually certain.

Norplant, Sterilizations, and Blood Transfusions

Another SRH procedure that may serve as a vector for nonsexual transmission of HIV is Norplant implantation. Norplant consists of six small flexible capsules which are surgically placed under the skin on the inner side of a woman’s upper arm where they are supposed to remain for five years and then be removed surgically. It should be noted that all progesterone-based approaches to contraception, including birth control pills, email an increased risk of contracting HIV. A 1996 study conducted by researchers at the Aaron Diamond AIDS Research Center in New York and supported by the World Health Organization found that the presence of progesterone likely thins the vaginal wall and thus makes it far more vulnerable to infection by STDs or HIV during intercourse.

Sterilizations, also encouraged in AIDS/SRH programs, provide an additional vector for infection.

Blood transfusions, often required in surgical procedures, are another major, though unquantifiable, risk. The World Health Organization’s Global Program on AIDS circulated estimates in 1988 that 6% of the HIV infections in Africa were due to blood transfusions. Still, as Gisselquist and Potterat write, “Importantly, [the data] point to injections — not blood transfusions — as the main health care risk.”38

Abortion and the Transmission of HIV/AIDS

Another sexual and reproductive health procedure that may have directly contributed to the spread of HIV/AIDS in Africa among women is the widespread practice of performing abortions with hand-held suction abortion syringes under the guise of “menstrual regulation” or “post-abortion care.” Since at least 1991 international Products Assistance Services (IPAS) has been manufacturing and distributing these syringes, generally referred to as manual vacuum aspirators or MVAs, to countries in Africa and elsewhere. An MVA consists of a long plastic tube attached to a large syringe. The model in current use, called the “IPAS Double-Valve Aspirator,” contains a 60cc aspirator, or syringe, to which plastic cannulae [tubes] sized 4–12mm can be attached “for use in uterine evacuation for several clinical indications.” The tube is inserted into the cervix, and the plunger on the syringe is pulled back by hand to suction out the contents of the uterus. “Aspirator holds evacuated tissue for easy examination,” IPAS assures the user.39 This crude and dangerous operation, known in many African clinics as simply “the procedure,” is the most common form of abortion in Africa. It is performed without anesthesia. up to and beyond 16 weeks gestation. A Marie Stopes International (MSI) clinic operator in Kenya told a PRI investigator that the procedure can be performed up to 20 or 24 weeks gestation “if the technician is brave.” But, he warned, “the women tend to cry.”

In the context of the HIV/AIDS epidemic in Africa, MVA abortions hold a significant risk of infection. First, the forcible dilation of the cervix can cause abrasions. Second, despite IPAS’s promise that “The flexible design [of the polyethelene plastic tube] can reduce the risk of uterine perforation,” this remains a significant risk, especially as the gestational age of the fetus to be aborted increases. Third, the “whistle cut” or “scoop” opening near the end of the tube can also scrape or nick the uterus.

The MVA and its detachable tubes not only can be reused again and again, it is intended to be reused. “Reusable aspirator results in very low per-procedure cost,” IPAS advertises. But it goes on to warn that “In the United States, the cannulae are strictly single-use. Where reuse is required and local regulations allow, the cannulae must undergo sterilization or high-level disinfection before reuse.”40 [italics added]

The cannulae are “strictly single-use” in the United States because plastic is notoriously hard to sterilize. So why would reuse be required in overseas settings like Africa where it is highly unlikely that the requirements laid down by the manufacturer for “sterilization or high — level disinfection” of these plastic tubes could be met? Because IPAS knows that its principal clients, which are USAID grantees and other agencies that purchase this abortion equipment for shipment to Africa, are supplying far too few cannulae for the number of abortions that are being performed.

Women visiting African clinics are rarely tested for HIV before being given an MVA abortion, and the syringes and the tube used for this procedure will almost certainly be reused. It is difficult to estimate the likelihood of transmitting the HIV virus by means of an infected MVA. Given the trauma and bleeding associated with the procedure, however, the transmission efficiency is probably as high or higher than that of an injection, which is 1 in 30. In 1997 the World Health Organization estimated that in Sub-Saharan Africa there were 4,400,000 unsafe abortions performed each year.41 If the number of MVA abortions performed annually is in this range, then these hand-held suction abortion syringes may be a prime vector of HIV/AIDS transmission, infecting hundreds of thousands of women each year.

While some HIV-positive women may be aborted by clinic personnel who do not know their HIV status, others may be specifically targeted for this procedure precisely because they have the disease. There is credible evidence that, in some countries, abortion is being used as a means of AIDS prevention. The U.N.’s World Health Organization (WHO) has condoned and promoted this method of preventing the mother-to-child transmission of AIDS, writing that “Access to safe abortion and counseling to ensure informed decision making and consent by the women, should be part of the services [for pregnant HIV positive women].”42 The HIV/AIDS epidemic is also being used by some to justify the legalization of abortion, on the grounds that the best way to prevent mother-to-child transmission is to end life in utero.

But is the risk of mother-to-child transmission (MTCT) as high as this suggests? MTCT can occur during pregnancy, at the time of delivery, and after birth through breastfeeding. According to the WHO, “Based on a compilation of studies, it is estimated that MTCT rates, without any anti-retroviral intervention, range from 15 to 30% in the absence of breastfeeding, to 25 to 35% if there is breastfeeding through 6 months and to 30 to 45% if there is breastfeeding through 18 to 24 months.”43 Delivery techniques can further reduce the rate of mother-to-child transmission, as can anti-retroviral therapy. Even without these kinds of special interventions, only one of every four or five babies born to seropositive mothers will be seropositive at birth, Most newborns of HIV/AIDS mothers do not carry the virus. Should all be terminated because some fraction of their number will contract the disease?

MVA abortion as “AIDS prevention” constitutes an absolute betrayal of trust. It is population control masquerading as HIV/AIDS prevention. It harms women, eliminates their unborn children, and further contaminates medical devices that will be used on subsequent HIV negative patients.

Condoms and “Safe Sex”

Over the past 20 years, HIV/AIDS prevention programs have centered on the large-scale distribution of condoms. These have been combined with “safe sex” propaganda campaigns aimed at convincing the public that putting a layer of latex between sexual partners can guarantee protection against infection by the HIV/AIDS virus. Population Services International, a USAID-funded group, uses aggressive and ubiquitous advertising campaigns to flood the media with a pro-condom message. These “safe sex” campaigns involve, to use PSI’s own martial language, a constant “barrage of radio spots and films shown on television, in cinema halls, and on [PSI’s] fleet of mobile film vans” all extolling the perfect protection afforded by condom usage.44

But the “safe-sex” approach has not been effective in reducing the incidence of HIV/AIDS. A study published in the Lancet found that promoting safer-sex made no difference in a Ugandan intervention trial.45 Numerous studies, on the other hand, have repeatedly shown that promoting abstinence and being faithful to a single sexual partner resulted in significant declines in HIV incidence in Uganda.

Over the course of the nineties, USAID shipped approximately 5 billion condoms abroad.46 Billions of others came from the UN Population Fund, the UK’s Overseas Development Agency, and other providers. Yet, despite this flood of condoms into the developing world, the rate of HIV/AIDS infection continued to grow at startling rates. The number of victims increased from just over 40,000 in 1990 to over 40 million in 2000. Why is this?

One answer may be suggested by a review of the scientific evidence on condom effectiveness conducted by the National Institutes of Health (NIH).47 NIH postulated that condoms, if consistently and properly used, provide an 85% reduction in HIV/AIDS transmission risk.48 While no one would deny that this reduction in risk is significant, it is far from being the perfect protection promised by the “safe sex” propaganda funded by USAID. Even paved with condoms, the road to promiscuity still leads to death.

To further complicate matters, the presumed protection resulting from using a condom may lead to behavioral changes that completely negate the protection. For example, an individual who believes that consistent and correct use of condoms provides near-absolute protection against HIV/AIDS may engage in recklessly promiscuous behavior that they would otherwise avoid. Why? Because they have been led to believe that, by practicing “safe sex,” they are immune from contracting the disease.

And so we come full circle. Family planning programs instituted to reduce fertility rates have actually contributed, in various ways, to the spread of AIDS.

This article is excerpted from PRI’s report on AIDS entitled AIDS, Abortion, and Effective U.S. Policy. For a copy of the complete report, please contact PRI.

Endnotes

1 USAID, Global Health, “HIV/AIDS: Frequently Asked Questions,” http://www.usaid.gov/pop_health/aids/News/aidsfaq.html#deaths.

2 UNAIDS, “AIDS Epidemic Update,” December 2002, p. 6.

3 United Nations Population Division (UNPD), 2000 Revision, Part One. Highlights of the 2000 Revision, III, “The Demographic Impact of HIV/AIDS”, p. 12.

4 Ibid., p. 13.

5 Brewer, David D., Brody, Stuart, Drucker, Ernest, Gisselquist, David, Minkin, Stephen F., Potterat. John J., Rothenberg, Richard B. and Vachon, Francois, “Mounting Anomalies in the Epidemiology of HIV in Africa: Cry the Beloved Paradigm,” International Journal of STD & AIDS, 2003, 14:144–147. Gisselquist, David, Potterat, John J., Brody, Stuart, and Vachun, Francois, “Let it be Sexual: how Health Care Transmission of AIDS in Africa was Ignored,” International Journal of STD & AIDS, 2003, 14:148–161. Gisselquist, David, and Potterat, John J., “Heterosexual Transmission of HIV in Africa: An Empiric Estimate,” International Journal of STD & AIDS, 2003, 14:162–173.

6 Piot, P., Plummer, F.A., Mhalu. F.S., Lainboray. J.L., Chin, J., Mann, J.M., “AIDS: An International Perspective,” Science, 1988, 239:573–9.

7 Chin, J., Sato, P.A., Mann, J.M., “Projections of HIV infections and AIDS cases to the year 2000. Bulletin. WHO. 1990, 68:1.11.

8 World Health Organization (WHO), “The World Health Report 2002: Reducing Risks, Promoting Healthy Life,” Geneva: WHO, 2002.

9 Quinn, T.C., Mann, J.M., Curran, I.W., Piot, P., “AIDS in Africa: an Epidemiologic Paradigm,” Science, 1986, 234:955–63. Van de Perre, P., Rouvroy, D., Lapage, P., et al, “Acquired Immune Deficiency Syndrome in Rwanda,” Lancet, 1984, ii: 62–65.

10 Gisselquist, David, et al, “Let it be Sexual: how Health Care Transmission of AIDS in Africa was Ignored,” p. 158.

11 Ibid.

12 Packard, R.M., Epstein, P., “Epidemiologists, Social Scientists, and the Structure of Medical Research on AIDS in Africa,” Social Science and Medicine, 1991, 33:771–83.

13 Brewer, et al, “Mounting Anomalies in the Epidemiology of HIV in Africa: Cry the Beloved Paradigm,” International Journal of STD & AIDS, 2003, 14:144–147, p. 145.

14 Gisselquist, et al, “Let it be Sexual: how Health Care Transmission of AIDS in Africa was Ignored,” p. 154.

15 Ibid., p. 152.

16 Ibid., p. 153.

17 Ibid., p. 154.

18 Ibid., p. 153.

19 Gisselquist, et al, “Heterosexual Transmission of HIV in Africa: An Empiric Estimate,” p. 171.

20 Drucker, E. M., Alcabes, P.G., Marx, P.A., “The Injection Century: Consequences of Massive Unsterilie injecting for the Emergence of Human Pathogens,” Lancet, 2001, 358:1989–92.

21 “USAID: Leading the Fight Against HIV/AIDS,” http://www.usaid.gov/pop_health/aids.

22 Population Action International (PAI), Fact Sheet, “How Reproductive Health Services and Supplies Are Key to HIV/AIDS Prevention.” http://www.populationaction.org/resources/factsheets/FactSheet18_AlDS.htm.

23 World Health Organization (WHO), “AIDS diagnosis and control: current situation; report of a WHO meeting,” WHO Regional Office For Europe, Munich, March 16–18, 1982. p. 2. USAID, Global Health, “HIV/AIDS: Frequently Asked Questions.” www.usaid.gov/pop_health/aids/News/aidsfaq.html. WHO, “Global Programme on AIDS, Progress Report 1992–1993”, 1995, p.2.

24 Gisselquist, et al, “Let it be Sexual: how Health Care Transmission of AIDS in Africa was Ignored,” p. 154. Lest it be thought that clinic attendees brought their HIV with them, Gisselquist, et al, go on to write that “Reported differences in HIV prevalence between clinic patients and controls and before and after STD treatment exceed differences in general population studies between persons with and without a history of STD.

25 Brewer, et al, p. 145. They cite an earlier study by Gisselquist, D., Rothenberg, R., Potterat, J., et al, “HIV Infections in Sub-Saharan Africa HDI Explained by Sexual or Vertical Transmission,” International Journal of STD & AIDS, 2002. 13:657–66.

26 “AIDS Epidemic Update,” Joint United Nations Programme on HIV/AIDS, UNAIDS/World Health Organization (UNAIDS/WHO), December 2002, p. 6.

27 Ibid., p. 19.

28 WHO, “Wastes from Health-Care Activities,” Fact Sheet No. 253, October 2000, p. 2., www.who.int/inf-fs/en/fact253.html.

29 WHO, “Safety of Injections: Misuse and Overuse of Injection Worldwide,” Fact Sheet No. 231, April 2002, www.who.int/inf-fs/en/fact231.html.

30 WHO, “Safety of Injections: Facts & Figures,” Fact Sheet No. 232, October 1999, p. 2, www.who.int/inf-fs/en/fact232.html.

31 WHO, “Waste from Health-Care Activities,” p. 2.

32 WHO, “Safety of Injections: Misuse and Overuse of Injection Worldwide,” p. 1.

33 Numbers are from the Population, Health and Nutrition Projects Database (PPD), http://ppd.phnip.com. PPD is a computer-based information system managed by the Population, Health, and Nutrition Information Project on behalf of USAID’s Center for Population, Health and Nutrition.

34 “New Era for Injectables,” Population Reports, 23(2), August 1995. Like most UN agencies, the UNFPA is extremely secretive about its operations. According to Population Reports, DMPA (Depo-Provera, Megastron) makes up three-quarters of UNFPA shipments of injectables, and NET EN (another injectable contraceptive) one-quarter. Thus in 1994 UNFPA shipped enough injectables for about 4.6 million woman-years of use. Deliveries of DMPA by the International Planned Parenthood Federation increased from 336,000 doses in 1991 to 735,000 in 1994. Deliveries of NET EN increased front 305,000 in 1991 to 438,000 in 1994.

35 Physicians information for Depo-Provera (medroxyprogesterone acetate injectable suspension), “Important Product Information,” www.depo-provera.com/index.asp.

36 According to Pharmacia and Upjohn, Depo-Provera is customarily available as 400 mg/ml in 2.5 ML vials. Since the standard dose is 150 mg, this means that each vial contains up to 6 doses. The Physicians Information warns that “any multi-dose use of vials may lead to contamination unless strict aseptic technique is observed… [special anti-septic solutions are] “recommended to cleanse the vial top prior to aspiration of contents.”

37 Immunization programs are another primary source of injection equipment which can, and undoubtedly is, being reused and abused in the African setting.

38 Gisselquist, et al, “Let it be Sexual: how Health Care Transmission of AIDS in Africa was Ignored,” p. 151.

39 http://www.ipas.org/english/products/mva.

40 Ipas, “Manual Vacuum Aspiration (MVA),” Flexible Karman Cannulae, http://www.ipas.org/english/products/mva/cannulae.html.

41 Unsafe abortion: Global and regional estimates of incidence of a mortality due to unsafe abortion with a listing of available country data, Third Edition, 1997, World Health Organization, “Chapter 4: “Estimating Regional and Global Incidence of, and Mortality Due to, Unsafe Abortion.” See esp. Table 2, “Global and regional annual estimates of incidence and mortality, unsafe abortions, United Nations regions, 1995–2000.” Since IPAS is a “Partner” of the WHO, these estimates presumably do not include the millions of abortions performed by MVA.

42 WHO, “Pregnancy and HIV/AIDS,” Fact Sheet No. 25, June 2000, www.who.int/inf-fs/en/fact250.html. See also WHO, “Human Rights, Women and HIV/AIDS,” Fact Sheet No. 247, June 2000, vww.who.int/inf-fs/fact247.html.

43 “Breastfeeding and Replacement Feeding Practices in the Context of Mother-to-child Transmission of HIV: An Assessment Tool for Research,” World Health Organization, Department of Reproductive Health and Research, WHO/RHR/0l.12, p. l.

44 Population Services International, “Bringing Mass Media to Rural Populations through Mobile Video Vans,” PSI flyer, November 1994

45 Anatoli Kamali, “Interventions for HIV prevention in Africa,” Lancet, 2003, 361(9358):633. See also AIDS Weekly, March 10, 2003, p. 16.

46 USAID, USAID Highlights, 6:4, 1989; USAID, Population, Health and Nutrition Projects Database. Note: the volume of USAID condoms shipped overseas is likely smaller than that of the UN Population Fund, which boasts of being the largest international supplier of condoms.

47 “Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention,” National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, July 20, 2001.

48 Davis, K.R., and Weller, S.C., “The Effectiveness of Condoms in Reducing Heterosexual Transmission of HSV,” Family Planning Perspectives, 1999, 31(6), p.272–279.

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