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EDUCATION AND DEBATE: Malcolm Potts and Julia Walsh Tackling India's HIV epidemic: lessons from Africa BMJ 2003; 326: 1389-1392 [Full text]

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What was the need for the picture?

ponnudas prabhakar   (21 June 2003)

AIDS in Africa?

David Rasnick   (22 June 2003)

AIDS Prevention:The Missing Key Component

Harold D Foster   (22 June 2003)

Tackling India's HIV Epidemic - Additional Lessons

George Hill   (22 June 2003)

Re: Tackling India's HIV Epidemic - Additional Lessons

Peter J Flegg   (23 June 2003)

Prevention is unsustainable without treatment

Julian T Meldrum   (25 June 2003)

Misrepresentation of 'Mainstream Agreement' Does Nothing to Support Alternative AIDS Theories.......

Tony Floyd   (25 June 2003)

Prevention is one of the best arguments for using HAART in Africa, India etc!

Jim Bond   (26 June 2003)

Out of Africa - evidence for effectiveness of abstinence

Trevor G Stammers   (27 June 2003)

HIV Treatments support HIV Prevention work

Ade O Fakoya   (27 June 2003)

Tackling India's HIV epidemic: Why Potts and Walsh should be ignored

Rajan Gupta   (29 June 2003)

Why India should disregard the advise of Potts and Walsh

Joe Thomas, Mridula Bandyopadhyay   (30 June 2003)

Scientific Institutions being co-opted to benefit commercial interests and political agendas by infl

Purushothaman Mulloli   (6 July 2003)

Global Failures and Local Successes in HIV prevention

Daniel Low-Beer   (9 July 2003)

Culturally Inappropriate Preventive Measures

Santhanam Sundar   (10 July 2003)

Tackling India’s HIV epidemic: lessons from Kerala

Stephen M Clift   (19 July 2003)

Controversial Article

Dr. Vikas Dhikav, New Delhi-110029   (9 September 2003)

What was the need for the picture? 21 June 2003
ponnudas prabhakar, SpR in Paediatrics King George Hospital, Goodmayes, Essex, IG3 8YB Send response to journal: Re: What was the need for the picture?	Dear Editor In the article by Potts and Walsh on India's HIV epidemic, I fail to understand the reasons behind the publication of the photo of a group of women labelled as "commercial sex workers in India". Especially, as there was no reference to this picture in the article. The credit for the picture reads "SIPA presses/ REX features". 1. Do we actually need a picture of these women to remind the reader as to how Commercial sex workers look - especially in India? 2. Are all the women in the photo commercial sex workers? 3. Were they consented either verbally or written for this photo to be published in the BMJ and if so was the consent unanimous among all the eight women? 4. Could the column not been used for something more productive? 5. Or is it that we need tabaloid like pictures in medical journals to sustain readers' interest? Yours sincerely P.Prabhakar Competing interests:   None declared
AIDS in Africa? 22 June 2003
David Rasnick, Visiting Scholar, Dept. MCB, UC Berkeley Berkeley, CA 94720 Send response to journal: Re: AIDS in Africa?	Dear Editor, The Education and Debate section dedicated to AIDS in the developing world assumes that there is an AIDS epidemic in the developing world. By 2001, Africa had reportedly generated a cumulative total of 1,093,522 AIDS cases (1). But, during this period the population of Sub-Saharan Africa had grown (at an annual rate of about 2.6% per year) from 378 million in 1980 to 652 million in 2000 (2). Therefore, a possible, above-normal loss of 1 million lives to AIDS is statistically hard to verify for two reasons: 1) the loss would be dwarfed by the overwhelming, simultaneous gain of 274 million people (the equivalent of the population of the USA), and 2) the African AIDS-defining diseases are indistinguishable from conventional African morbidity and mortality. Because of the many epidemiological and clinical differences between African AIDS and its American/European namesake, and because of the many uncertainties about the statistics on African AIDS, both the novelty of African AIDS and its relationship to American/European AIDS have recently been called into question (3-11). Indeed, all available data are compatible with a perennial African epidemic of poverty-associated diseases under the new name AIDS (12,13). Because the WHO decided in 1985 to accept AIDS diagnoses without an HIV-test, there is no reliable documentation for even an HIV epidemic in Africa (4,14). Such presumptive diagnoses were approved because the cost of the HIV-antibody test is prohibitive for most Africans. As a result, there are huge discrepancies in African AIDS statistics. For instance, based on WHO information, the Durban Declaration claimed in 2000 that, "24.5 million...are living with HIV or AIDS in Sub-Saharan Africa". However, the WHO had reported no more than 81,565 new cases AIDS for the whole African continent in that year (obtained by subtracting the cumulative total of 794,444 in 1999 from the cumulative total of 876,009 in 2000) (15,16). The richest country in sub-Saharan Africa is South Africa, which has the most reliable statistics on the continent. Statistics South Africa (Stats SA) reports a constant growth in the population of South Africa from 38 million in 1994 to 43 million in 2001 (17,18). Furthermore, the rise in the number of deaths from all causes during the same period was also constant, growing as the population grows-but no faster. In fact, there was a slight decline in deaths for both 2000 and 2001. To get around the embarrassing problem of having to reveal that the Medical Research Council (MRC) has no hard data on how AIDS had affected South Africa up to 2003, its "National Burden of Disease Study" says that it did not analyze the burden of diseases for earlier periods. Instead, the authors preemptively declare that, "the disease burden in SA is undergoing rapid change due the spread of HIV/AIDS". Clearly, without hard data on how disease and death have changed over time, there is no way to quantify or even justify the MRC's assertion. Indeed, data from Statistics South Africa (Stats SA) flatly contradicts the MRC. To be sure, there are claims of increased AIDS deaths in South Africa. These new "statistical" AIDS deaths result from reclassifying TB deaths (as well as deaths from other illnesses) as "true" AIDS deaths. The stealing from Peter-to-pay-Paul actuarial trick allows the reporting of more AIDS deaths at the expense of other causes, without increasing the overall death rate. The MRC's claim that, "AIDS was responsible for about 39% of premature deaths in 2000" is nothing short of fraud. The hysteria that "Premature deaths from Aids [are] likely to double by 2010" is pure fantasy. African AIDS is assumed to be sexually transmitted The assumptions 1) that HIV is sexually transmitted and 2) there are "24.5 million...living with HIV or AIDS in Sub-Saharan Africa" (19) produce a sexual paradox. The fact that mainstream HIV researchers have agreed that it takes on average 1000 unprotected sexual contacts with HIV-positive partners to transmit HIV (11,20,21) means that an extraordinary degree of sexual promiscuity is necessary in order to sustain a sexually transmitted AIDS epidemic. Therefore, the level of sexual promiscuity in Africa must be significantly greater than that in the USA and Europe where the promised heterosexual AIDS epidemics never materialized. Thus, in order to produce an African AIDS epidemic on the scale repeatedly reported in the New York Times, by the WHO and UNAIDS requires massive, random sexual promiscuity, far beyond that seen in the USA and Europe. The number of random sexual contacts needed to spread a sexually transmitted HIV epidemic in Sub-Saharan Africa is a straight forward calculation. Since only 1 in 26 (24.5 million per 652 million) of Sub-Saharan Africans was HIV-positive in 2000, each of the 24.5 million must have had an average of 1000 x 26 = 26,000 sexual contacts to reach the 1000 HIV-positive contacts needed to acquire HIV and to spread an epidemic. It strains credulity to accept that poor, hungry Sub-Saharan Africans are engaging in such levels of sexual promiscuity. Indeed, the evidence is strongly against it. A recent thorough epidemiological study of sexual transmission of HIV in Africa found the same "low rates of heterosexual transmission [of HIV], as in developed countries" and "no correlation between the percent of adults...reporting non-regular sexual partners...and HIV prevalence" (11). These and other anomalies led Brewer et al. to "propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African epidemic" (22). Thus, either the assumption of the Durban Declaration that HIV is sexually transmitted, or its claim that 24.5 million are HIV-positive, or both are flawed. Nevertheless, we continue to read in newspapers and hear on television that 25 million people have died of AIDS, and there are upwards of 40 million people infected with HIV-and most of these are said to be in Africa. The latest antenatal screening survey in South Africa (23) also failed to support the hypothesis that HIV is sexually transmitted but instead confirms the conclusion of Brewer et al. that, "HIV is not transmitted by 'sex'" (22). The survey included testing pregnant women for syphilis and antibodies to HIV in order to see how the two diseases were correlated by geographical location and over time. But, there was no correlation. On the contrary, KwaZulu- Natal, which is leading when it comes to HIV, has the lowest rate of syphilis in all provinces. Western Cape, on the other hand, had the highest rate of syphilis in 2000 but the lowest HIV prevalence. Northern Cape had the highest rate of syphilis in 2001 but the third lowest prevalence of HIV antibodies in that year. Paradoxically, then, there is an inverse geographical correlation between syphilis and HIV although both are said to be transmitted by heterosexual intercourse. An even more extraordinary result is the divergence over time between an increasing prevalence of antibodies to HIV and a declining rate of syphilis. This is also difficult to understand given the assumption that both are sexually transmitted. A recent study in Uganda presents yet another paradoxical result. The intention of the study had been to reduce HIV incidence by mass treatment of STDs with conventional antibiotics. The rationale behind the study was that reducing STDs (which was assumed to be a co-factor in the transmission of HIV) should reduce the transmission of HIV. However, the result of the study was paradoxical. While the investigators were very successful in significantly reducing STDs, their intervention had "no [effect] on incidence of HIV-1 infection..." (24). The data from Thailand show that these paradoxical results are not peculiar to Africa. Even though Thailand is said to be severely hit by a heterosexually transmitted HIV-epidemic, we find yet again the same scenario presented by South Africa and Uganda. Bangkok has the highest rate of STDs but low HIV prevalence. Conversely, the so called Golden Triangle of northern Thailand has the highest rate of HIV but the second lowest STD morbidity of all regions. And, even within the different provinces of the Northern Region there is a negative correlation between HIV and syphilis (25). The conclusion from these observations is obvious: HIV cannot be heterosexually transmitted. African AIDS numbers are based on HIV-antibodies in pregnant women Before 1998, two HIV-antibody tests had been performed for the South African surveys: one screening test and a confirmation test on the positive samples. The second test was skipped from 1998 onwards, except in Western Cape, even though generally it is the accepted standard to do at least two tests. Furthermore, the manufacturer of the HIV-antibody test that was used in the surveys specifically warns that, "non-specific reactions may be seen in samples from some people who, for example, due to prior pregnancy...have antibodies to the human cells or media in which HIV-1 is grown for manufacture of the EIA" (26). In other words the test, which may show false positive reactions in women with "prior pregnancy", is being used in pregnant women without further confirmation or adjustment. The insert that comes with the antibody test also warns that, "at present there is no recognized standard for establishing the presence or absence of HIV-1 antibody in human blood." This probably explains why "Studies from seven African countries over the last 15 years show rates of HIV incidence during antenatal and/or post-partum periods exceeding what could be expected solely from sexual transmission" (27). Yet, these problematic, unconfirmed results from pregnant women are than used to estimate the frequency of HIV in the general population (28) and eventually the whole of Sub-Saharan Africa. Thus, there is no evidence that HIV is spreading through sexual intercourse (or any other way) in Africa or anywhere else. Combined with the evidence that Africa is not currently being devastated and depopulated by an AIDS epidemic, the inability to document a sexually transmitted epidemic of HIV shows that a future HIV-caused AIDS apocalypse in Africa is unlikely. AIDS by Prescription The purpose of the HIV fraud is to justify a third-world-wide assault with the anti-HIV drugs. These drugs are among the most toxic substances ever approved for human use. So toxic, in fact, that the US FDA requires black box warning labels listing the diseases and deaths caused by these drugs. AZT used for research purposes comes with an orange and white label bearing a skull and cross bones and the warning: "TOXIC. Toxic by inhalation in contact with skin and if swallowed. Target organ(s): Blood bone marrow. If you feel unwell, seek medical advice (show the label where possible). Wear suitable protective clothing". AZT and similar drugs kill bone marrow cells and are consequently highly immune suppressive. This fact poses one of the most disturbing aspects of the HIV fraud. If the current standard of care in the USA is adopted, then developing world physicians will be obliged to treat their immune suppressed patients for life with the severely immune suppressive anti-HIV drugs. If the patients taking AZT somehow manage to survive the acute toxicity of the drug, they can look forward to a 50:50 chance of developing lymphoma 36 months after initiation of therapy (29). David Rasnick Member of the South African Presidential AIDS Advisory Panel References 1. World Health Organization. (2001) Global situation of the HIV/ AIDS pandemic, end 2001 Part I, Weekly epidemiological record 76, 381-384 2. U.S. Bureau of the Census International Data Base. (2001) World population by region and development category: 1950- 2025, Washington, DC, U.S. Department of Commerce, Bureau of the Census, March, 1999, 3. Hodgkinson, N. (1996) AIDS: the failure of contemporary science, Fourth Estate, London, UK 4. Fiala, C. (1998) in New African, pp. 36-38 5. Shenton, J. (1998) Positively False: exposing the myths around HIV and AIDS, I. B. Tauris, London/New York 6. Stewart, G. T., Mhlongo, S., de Harven, E., Fiala, C., Koehnlein, C., Herxheimer, A., Duesberg, P., Rasnick, D., Giraldo, R., Kothari, M., Bialy, H., and Geshekter, C. (2000) The Durban Declaration is not accepted by all, Nature 407, 286. 7. Malan, R. (2001) in Rolling Stone Vol. 22 November, pp. 70-72, 74-78, 80, 82, 100, 102 8. Gellman, B. (2000) in Washington Post, pp. A01, Washington, DC 9. Fiala, C., de Harven, E., Herxheimer, A., Kohnlein, C., Mhlongo, S., and Stewart, G. T. (2002) HIV/AIDS data in South Africa, Lancet 359, 1782 10. Ross, E. (2003) in Reclaiming Knowledge for Diversity (Pimbert, M., ed), pp. in press, Routledge or Earthscan 11. Gisselquist, D., Rothenberg, R., Potterat, J., and Drucker, E. (2002) HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission, Int J STD AIDS 13, 657-666 12. Konotey-Ahulu, F. I. D. (1987) Clinical epidemiology, not seroepidemiology, is the answer to Africa's AIDS problem, BMJ 294, 1593-1594 13. Konotey-Ahulu, F. I. D. (1987) AIDS in Africa: Misinformation and disinformation, Lancet ii, 206-207 14. World Health Organization. (1986) Provisional WHO clinical case definition for AIDS, Weekly Epidemiological Records March, 7, (10), 72-73 15. World Health Organization. (2000) Global AIDS surveillance, Part I, Weekly Epidemiological Record 75, 379-383 16. World Health Organization. (1999) Global AIDS surveillance, Part I, Weekly Epidemiological Record 74, 401-404 17. Statistics South Africa. (2002) Causes of death in South Africa 1997-2001http://www.statssa.gov.za/default3.asp 18. Statistics South Africa. (2000) South African Statistics 2000http://www.statssa.gov.za/default3.asp 19. The Durban Declaration. (2000) The Durban Declaration, Nature 406, 15-16 20. Padian, N. S., Shiboski, S. C., Glass, S. O., and Vittinghoff, E. (1997) Heterosexual transmission of human immunodeficiency virus (HIV) in Northern California: results from a ten-year study, Am. J. Epidemiol. 146, 350-357 21. Jacquez, J. A., Koopman, J. S., Simon, C. P., and Longini Jr., I. M. (1994) Role of the primary infection in epidemics of HIV infection in gay cohorts, J. Acquired Immune Deficiency Syndromes 7, 1169-1184 22. Brewer, D. D., Brody, S., Drucker, E., Gisselquist, D., Minkin, S. F., Potterat, J. J., rothenberg, R. B., and Vachon, F. (2003) Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm, International Journal of STD & AIDS 14, 144- 147 23. Makubalo, L. E., Netshidzivhani, P. M., Mulumba, R., Levin, J., du Plessis, H., Ratsaka, M., Mahlasela, L., Mudzanani, L., Johnson, C., and Shikweni, F. (2001) Summary Report:NATIONAL HIV AND SYPHILIS SERO-PREVALENCE SURVEY IN SOUTH AFRICA, Pretoria, South Africa, Directorate: Health Systems Research, Research Coordination and Epidemiology, http:// 196.36.153.56/doh/index.html 24. Wawer, M. J., Sewankambo, N. K., Serwadda, D., Quinn, T. C., Paxton, L. A., Kiwanuka, N., Wabwire-Mangen, F., Li, C., Lutalo, T., Nalugoda, F., Gaydos, C. A., Moulton, L. H., Meehan, M. O., Ahmed, S., and Gray, R. H. (1999) Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomised community trial. Rakai Project Study Group, Lancet 353, 525-535 25. Chitwarakorn, A. e. a. (1998) Sexually Transmitted Diseases in Asia and the Pacific, Ministry of Public Health, AIDS Division, HIV/ AIDS Situation in Thailand, Region 10, Chiang Mai, Thailand 26. Abbott Laboratories Diagnostics Division. (1997) Human Immunodeficiency virus type 1 HIVAB HIV-1 EIA, Abbott Park, IL, Abbott Laboratories, 66-8805/R5 27. Gisselquist, D., Rothenberg, R., Potterat, J., and Drucker, E. (2002) HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission, Int J STD AIDS 13, 657-666 28. Ntsaluba, A. (2000) National HIV and Syphilis Sero- Prevalence Surveyof women attending Public Antenatal Clinics in South Africa 2000, Pretoria, South Africa, Ministry of Health, Director-General for Health, 13 pages, http://196.36.153.56/doh/ facts/index.html 29. Pluda, J. M., Yarchoan, R., Jaffe, E. S., Feuerstein, I. M., Solomon, D., Steinberg, S. M., Wyvill, K. M., Raubitschek, A., Katz, D., and Broder, S. (1990) Development of non-Hodgkin lymphoma in a cohort of patients with severe human immunodeficiency virus (HIV) infection on long-term antiretroviral therapy, Ann Intern Med 113, 276-282 Competing interests:   None declared
AIDS Prevention:The Missing Key Component 22 June 2003
Harold D Foster, Professor University of Victoria ,Victoria,Canada V8W 3P5 Send response to journal: Re: AIDS Prevention:The Missing Key Component	With the exception of the shareholders of the pharmaceutical companies,there are few who would disagree with Potts and Walsh's position that cheap prevention is better than expensive cure.That being said,it is also clear that preventative strategies that rely on individual action, such as the use of condoms to reduce the spread of HIV-1,are much less likely to succeed in the long-term than those that can be applied at the community level. It is very obvious that HIV-1 is spreadig fastest in selenium-deficient populations and that this phenomenon accounts for much of its rapid diffusion in Southern Africa (1)and amongst the U S Afro-American population (2).This geographical prevalence pattern should not be too surprising since HIV-1 is a member of a group of viruses,including Hepatitis B and C and Coxsackievirus B3, that encodes for glutathione peroxidase (3). Such viruses are much more likely to infect selenium- deficient populations but can be prevented from doing so by increasing dietary selenium intake.The Chinese,for example,have greatly reduced the incidence of hepatitis B and C and Keshan disease (Coxsackievirus B3) by strategies such as adding selenium to table salt,animal feed and fertilizers (4-5). Unfortunately,on a global scale,rather than increasing the level of selenium in the food chain,we are reducing it through acid rain.It is not surprising that a third of the global population is now infected with one or more of these selenoenzyme-encoding viruses.Regardless of which of these viruses is involved,it reduces available serum selenium,making the individual more susceptible to infection by HIV-1 and by all other members of the viral group.The widespread addition of selenium to the food chain would be the quickest,cheapest and most effective method of slowing the diffusion of HIV/AIDS in India.It could be used in combination with every other strategy suggested by Potts and Walsh. References 1.Foster HD.Why HIV-1 has diffused so much more rapidly in Sub-Saharan Africa than in North America.Med Hypotheses 2003;60(4):611-4. 2.Cowgill GM. The distribution of selenium and mortality owing to Acquired Immune Deficiency Syndrome in the continental United States. Biol Trace Element Res 1997;56:43-61. 3.Taylor EW,Bhat A,Nadimpalli RG,Zhang W,Kececioglu J.HIV encodes a sequence overlapping env gp41 with highly significant similarity to selenium-dependent glutathione peroxidases.J AIDS Human Retrovirol 1997;15:393-4. 4.Yu S,Li WG,Zhu YJ,Hou C.Chemo-prevention trials of human hepatitis with selenium supplementation in China.Biol Trace Element Res 1989;20(1-2):15- 22. 5.Editorial Board.The Atlas of Endemic Diseases and Their Environments in the People's Republic of China.Beiging:Science Press,1985. Competing interests:   I am the author of the book "What really causes AIDS" which is available free at www.hdfoster.com and have a patent pending on a method of reversing AIDS using nutrients.
Tackling India's HIV Epidemic - Additional Lessons 22 June 2003
George Hill, Executive Secretary Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107, USA Send response to journal: Re: Tackling India's HIV Epidemic - Additional Lessons	EDITOR--Potts & Walsh compare India to sub-Saharan Africa.1 They apparently believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of human immunodeficiency virus (HIV), and that male circumcision is an effective remedy. They argue for the circumcision of Hindu people to reduce the transmission/reception of the virus in India.1 Discussion       It has been believed since about 1988 that heterosexual coitus accounts for 90 percent of the HIV infection in Africa.2 Many studies do argue that circumcision can reduce the transmission of HIV through heterosexual coitus. The quality of these studies has been criticized for their methodological flaws, including their failure to control for numerous confounding factors.3,4       Potts & Walsh1 rely on Szabo & Short’s argument that a programme of male circumcision could control spread of HIV.5 However, Szabo & Short’s claims remain controversial.6       Gray et al. found that transmission by coitus “is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa.”7       The human foreskin has physiological functions designed to protect the human body from infection. The sub-preputial moisture contains lysozyme,8 an enzyme that attacks HIV.9 Circumcision destroys this natural protection.       Circumcision removes erogenous tissue,10 desensitizes the penis,11 changes sexual behavior and makes males more likely to engage in unsafe sex practices.12 Circumcised males, therefore, are less willing to use additionally desensitizing condoms.5       A program of mass circumcision would expose Hindu males to unsafe genital cutting,4 would destroy the natural protection of the foreskin,8,9 would not be effective against iatrogenic unsafe health care,3 and, therefore, is likely to increase the transmission of HIV.4       Circumcision has not yet been shown to be an effective deterrent against HIV infection.3,4 The Council on Scientific Affairs of the American Medical Association says that “circumcision cannot be responsibly viewed as ‘protecting’ against such infections.”13 Religious Factors       The practice of circumcision is associated with the Muslim religion, although it is not required by the Qu’ran. Hindu males may be resistant to the adoption of a practice associated with a religion that is not their own. Sikhs generally are opposed to the cutting of the body.       It may be difficult to gain acceptance for circumcision as a prophylactic practice in India because of the religious factors. Recent developments       It now appears that these studies have not accounted for the largest confounding factor of all-iatrogenic transmission of HIV. Three companion articles published recently in the International Journal of STD & AIDS call into question the conventional wisdom that heterosexual coitus is responsible for 90 percent of HIV infection in sub-Saharan Africa.14-16 It is now estimated that heterosexual coitus accounts for no more than 30 percent of infection-only one-third of the previous estimate. Heterosexual transmission of HIV that one sees in Africa also cannot explain the incidence of HIV in children.15,17 The evidence now points to unsafe health care as the primary vector for HIV infection.       Even if circumcision were effective in preventing HIV infection, it could not be effective against the approximately 70 percent of infections that are not transmitted sexually. If health care is unsafe, then medical circumcisions also would be unsafe. A programmme of mass medical circumcisions could cause increased infection.5 Bioethics and Human Rights       Finally, we would like address on legal and ethical issues. As noted above, male circumcision excises a large amount of functional healthy erogenous tissue from the penis.10 It is a clear violation of the basic human right to security of the person.18       Several authorities report that circumcision degrades the erectile function of the penis.19,20 Circumcision, therefore, must be regarded as degrading treatment. Degrading treatment is an additional violation of human rights.21       The leading international statement of medical ethics is the European Convention on Human Rights and Bioethics.22 Article 20(1) prohibits non-therapeutic tissue removal from those who do not have the capacity to consent. Children have a right to the protection of the security of their person17,21 and to protection from degrading treatment.20, 22 Circumcision would violate those human rights. Doctors must respect patient human rights.23       This means that prophylactic circumcisions ethically may not be carried out on minors. Circumcisions, therefore, would have to be limited to adult males who legally may give informed consent. Conclusion       Potts and Walsh accept without question that HIV is primarily transmitted in Africa by heterosexual coitus and that circumcision reduces or prevents the transmission of HIV,1 but medical authorities do not accept the evidence of this—the United States Center for Disease Control, the British Communicable Disease Surveillance Centre, and UNAIDS do not recognize circumcision as an effective public health measure.       It is now believed that unsafe health care is the major vector for the transmission of HIV in Africa. Potts and Walsh have not shown that the health care system in India is safer.1 If health care in India, is as unsafe as health care in Africa, unsafe circumcisions may be a vector for infection.       It is not clear that intact Hindu males who personally experience the erogenous quality of the foreskin10,11 would be willing to sacrifice their erogenous tissue for the dubious protection of circumcision.       Even if circumcision eventually is shown to provide some protection against HIV infection, that protection can only work to reduce the 30 percent of infections that now are attributed to sexual activity. It would have no effect on the other 70 percent. Its effect, therefore, would be minimal at best and could not have an effect for the first fifteen years by which time behavioral changes could be introduced into society through education, and a HIV vaccine may well be developed to provide immunity.       Circumcision would divert scarce medical and social resources from areas of proven effectiveness,5 so also for that reason may be counter-productive.       There is no credible evidence that circumcision can reduce the risk of HIV infection. Concentration on proven means of disease control is indicated. George Hill Executive Secretary Doctors Opposing Circumcision Suite 42 2442 NW Market Street Seattle, Washington 98107 USA Web: http://www.doctorsopposingcircumcision.org/  References: Potts M, Walsh J. Tackling India's HIV epidemic: lessons from Africa. BMJ 2003;326:1389-92. Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries. BMJ 2002;324:235. de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994;8(2):153-160. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000;320: 1592-4. Van Howe RS, Cold CJ, Storms MR. Some science would not have gone amiss. BMJ 2000;321:1467. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: 1149-53. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. Lee-Huang S, Huang PL, Sun Y, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci U S A 1999;96(6):2678-2681. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-29. Falliers CJ. Circumcision. JAMA 1970;214(12):2194. Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057. Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999. Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS 2003;14:144-7. Gisselquist D, Potterat JJ, Brody S. Let it be sexual: how health care transmission of HIV was ignored. Int J STD AIDS 2003;14:148-61. Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162-73. Brody S, Gisselquist D, Potterat JJ, Drucker E. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol 2003;110:450-2. Article 3, Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948). Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol 2001;166(6):2273-6. Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116. Article 5, Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948). Council of Europe. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997. Article 37, U.N. Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25. Council on Ethical and Judicial Affairs. Principles of Medical Ethics. Chicago: American Medical Association, 2001. Competing interests:   None declared
Re: Tackling India's HIV Epidemic - Additional Lessons 23 June 2003
Peter J Flegg, Consultant Physician Blackpool Victoria Hospital, FY3 8NR Send response to journal: Re: Re: Tackling India's HIV Epidemic - Additional Lessons	I would like to take issue with some points raised by George Hill in his valuable contribution to the examination of these issues. (http://bmj.com/cgi/eletters/326/7403/1389#33552) Firstly, he states that Gray et al. found that transmission by coitus "is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa." This is a misquote, and one that I often see cited. Gray actually states: "greater infectivity of predominant HIV-1 viral subtypes is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa". The Rakai project team conducted a study to examine the hypothesis that differences in infectivity of the prevalent HIV-1 subtypes (A and D) was responsible for the epidemic in East and Southern Africa. If Gray concludes anywhere in his article that "coitus" is not responsible for the epidemic I would be grateful if George Hill could show me where. Secondly, it is a little disingenuous to broadly claim that "It is now believed that unsafe health care is the major vector for the transmission of HIV in Africa." This may be the view of some, but not the majority. Following the publication of Gisselquist's articles, the WHO has responded by issuing a statement from its expert group which reaffirming the view that "unsafe sexual practices continue to be responsible for the overwhelming majority of infections". http://www.who.int/mediacentre/statements/2003/statement5/en/ Competing interests:   None declared
Prevention is unsustainable without treatment 25 June 2003
Julian T Meldrum, International Editor, www.aidsmap.com NAM, Lincoln House, 1 Brixton Road, London SW9 6DE Send response to journal: Re: Prevention is unsustainable without treatment	It is really disappointing to read yet another re-run of the old idea that money should not be devoted to providing effective treatment for people with AIDS because HIV prevention is “more cost-effective”. I had hoped that sensible people had moved beyond this notion. Certainly, the leadership of WHO, UNAIDS, US Presidents Clinton and Bush, former South African President Nelson Mandela, the World Bank and many other stakeholders have done so. The lobby for the provision of antiretrovirals in Africa, Asia, the Caribbean and Latin America is not purely “emotional” and does not solely consist of people with HIV who have access to treatment in wealthier countries. However, the latter group is fully entitled to ask why the lives of their counterparts in Africa and Asia must be cut short for lack of less than US $1,000 a year in treatment costs. After all, on the same logic, cancer treatment services and cardiac surgery in the NHS should be closed down because antismoking campaigns and the promotion of fruit and vegetables and regular exercise could save lives more “cost-effectively”. While we’re about it, many ambulances and accident and emergency departments could be de-funded in favour of hidden speed cameras, speed-limiters on all motor vehicles and 20mph (32kph) speed limits on our roads to go with them. The only problem, of course, is that a society which abandons its casualties - or maybe restricts treatment to a few cheap painkillers - is not a civilised society in any sense that most of us would recognise. Emotion is not totally out of place in a civilised society and is not always irrational. Key points that Potts and Walsh have failed to confront in arguing for spending on HIV prevention to the exclusion of effective treatment, including antiretrovirals, include: · The “emotional” impact on healthcare staff of seeing young adults, including their own colleagues and family members, die prematurely from diseases that they know perfectly well could be treated for a relatively small amount of money. · The “emotional” disincentive to get tested for HIV - which even Potts and Walsh want to promote, quite rationally, in order to encourage personal responsibility for and identification with HIV prevention messages - if people with HIV are barred from public hospitals, education and professional training on the rational grounds that they will shortly die and it would therefore be a waste of money to treat or train them further. · The “emotionally” stigmatising effect of persistent identification of an AIDS diagnosis with an early death, and the opposite effect which occurs when someone who has been at death’s door is restored to life and health. Such people, oddly enough, tend to want to tell other people about their experience. Strangely, the experience is much the same, whatever part of the world those people live in. In addition, many people are driven to wonder at the logic which provides "highly cost effective" short-course antiretroviral treatment to prevent transmission of HIV from mothers to babies, and then denies treatment to the babies' parents who die, leaving their children highly vulnerable to a wide range of social disadvantages for the rest of their lives. I hope that Indian policy makers will draw entirely different conclusions from the ones proposed by Potts and Walsh and will observe that their competent and innovative domestic pharmaceutical industry, which has already driven down the cost of ARV treatment to a considerable degree, could do even better if assured of a steady domestic public sector market for its products. Competing interests:   Editor, 'HIV & AIDS Treatment in Practice', a free electronic newsletter for those providing treatment and care to people with HIV and AIDS in limited-resource settings. NAM, its publisher, but not the newsletter itself, receives unrestricted educational grants from a number of pharmaceutical companies listed on www.aidsmap.com, the organisation's website.
Misrepresentation of 'Mainstream Agreement' Does Nothing to Support Alternative AIDS Theories....... 25 June 2003
Tony Floyd, Medical Student Newcastle University, Newcastle Australia Send response to journal: Re: Misrepresentation of 'Mainstream Agreement' Does Nothing to Support Alternative AIDS Theories.......	The following statement has been made above: > The fact that mainstream HIV researchers have agreed that it takes on average 1000 unprotected sexual contacts with HIV-positive partners to transmit HIV (11,20,21) means that an extraordinary degree of sexual promiscuity is necessary in order to sustain a sexually transmitted AIDS epidemic. The three papers referenced as 11, 20 and 21 are noted below(1,2,3). Not one of them in any way indicates that mainstream (whatever that means) researchers have agreed that 1000 unprotected contacts are required to transmit HIV. The Padian paper(2) provides no such estimate. One cannot just extrapolate what happened in her study of wealthy, educated and mostly condom wearing Northern Carolinan couples who knew one of them had HIV to somehow apply to Africa or anywhere else. Padian did not attempt to use her study in such a way, and nobody has published any such interpretation. Please advise in which part of the paper she 'agreed' to the transmission ratio given. The Jacquez paper(3) clearly states that: --- "A review of the data on infectivity per contact for transmission of the HIV suggests that the infectivity may be on the order of 0.1-0.3 per anal intercourse in the period of the initial infection" --- Aside from the fact that the Jacquez paper was only studying cohorts of homosexual males, why did you reference it to claim that their is 'agreement' amongst experts about sexual contacts in general? During early infection at least Jacquez did find an infectivity between 1 in 10 and 1 in 3. A long way from the 1 in 1000 that you referenced to his paper. That's a VERY big difference. Gisselquist's research suggests that iatrogenic causes have been underestimated, it does not suggest that their is consensus amongst experts about the transmission rate given. None of the three references hence in any way support the claim made. Extraordinary claims require extraordinary proof. What has been presented here to support alternative AIDS theories is just plain ordinary. *** References: (1) Gisselquist, D., Rothenberg, R., Potterat, J., and Drucker, E. (2002) HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission, Int J STD AIDS 13, 657-666 (2) Padian, N. S., Shiboski, S. C., Glass, S. O., and Vittinghoff, E. (1997) Heterosexual transmission of human immunodeficiency virus (HIV) in Northern California: results from a ten-year study, Am. J. Epidemiol. 146, 350-357 (3) Jacquez, J. A., Koopman, J. S., Simon, C. P., and Longini Jr., I. M. (1994) Role of the primary infection in epidemics of HIV infection in gay cohorts, J. Acquired Immune Deficiency Syndromes 7, 1169-1184 Competing interests:   None declared
Prevention is one of the best arguments for using HAART in Africa, India etc! 26 June 2003
Jim Bond, SpR in Public Health Dept of Public Health Sciences, University of Edinburgh Medical School, Edinburgh EH8 9AG Send response to journal: Re: Prevention is one of the best arguments for using HAART in Africa, India etc!	Goodness me - There is some weird and wonderful debate on HIV in Africa on this site! Having said that, there is much to take issue with in Potts and Walsh’s highly opinionated paper. For example: 1. ‘HIV infection begins in the core groups of commercial sex workers, intravenous drug users and men who have sex with men.’ This sweeping statement does not universally hold, particularly in Africa. Certainly, people who take part in certain high-risk activities may accelerate the course of an epidemic, but that does not necessarily mean they should be held responsible for introducing it, nor for its continued transmission it once it gets a foothold within a population. HIV is with us all now. Continuing to focus on such ‘target group’ classifications, with its accompanying hidden message of ‘them, not us’ is becoming less and less regarded as constructive health promotion for HIV anywhere - let alone in a culture such as India, where open discussion of sexual matters is still largely taboo! 2. ‘One emerging lesson is that money spent on anti-retroviral drugs is money removed from prevention, and vice versa.’ Firstly, the two references cited to support this irresponsible statement are hardly evidence on which to base practice. True, those countries fortunate enough to be able to take early advantage of this new technology have had to pay a high price, which has often come out of a diminishing per capita pot for HIV services overall. This is the case with the NHS in Scotland, which is usually a lot cannier than the USA, when it comes to waiting for the price to come down. With a disease like HIV, however, we couldn’t afford not to treat – for public health and economic, as well as ethical reasons. Middle income countries such as Brazil (Flynn, 2002) and Botswana, were also quick to do the sums... Brazil’s foresighted early implementation may well have directly led to the drop in incidence noted there (Hosseinipour, 2002). Now, as global prices for HAART tumble towards something nearer reality in the developing world, Global Fund support and differential pricing, cost-effective treatment, e.g. via appropriate, simple, low-tech approaches such as community-based, DOT- HAART (Farmer, 2001), is now almost within grasp for most of those who need it. The point Potts and Walsh appear to miss is that HAART, particularly in the African context, is an essential component of HIV prevention, at all (primary, secondary and tertiary) levels. HAART goes hand in hand with and augments other more traditional HIV prevention approaches, particularly when it is done openly and visibly at community level. Seeing someone with end- stage AIDS get better and get back to work, able to look after their kids again, is one of the best ways to overcome the fear and ignorance that underlies stigma. It also gives people hope; that it might be worth looking after their health, as well as that of their community, after all. Along with the right of access to ARV’s, goes responsibilities - for both an individual and their community. If the elders have to show that they are serious about owning and managing the AIDS problem in their midst, e.g. by delegating people to act as (lay) treatment supporters, coordinating support for orphans, providing proper sexual and reproductive health education to the young, and dealing firmly with sugar-daddies and rapists… then we might get somewhere. I know of no pro-treatment campaigners who would advocate anything less. NB It has also been shown (Kazatchkine, 2002) that the cost- effectiveness of ‘pure’ preventive measures follows the law of diminishing returns as you try to reach the ‘hard-to-reach’, in contrast to a well-running HAART programme, with its various, sustained 1?, 2? and 3? protective effects. 3. ‘These drugs are difficult to use (except to prevent MTCT) and… are very expensive, especially when the necessary testing, monitoring, and counselling costs are included.’ No, they’re not – HAART is pretty straightforward to prescribe nowadays! As for fancy tests (e.g. viral load and CD4) and physician-based monitoring, these are also not ‘necessary’ in the African context, where resources can be better used to provide a well-operating, community-based, DOT-HAART system. Similarly, imported, Californian notions of how elaborate, one-to-one counselling should be given, by trained professionals etc… - these often do more harm than good! 4. ‘The international donor community should ensure that priority is given to funding condoms and antibiotics before funding other programmes’ I have worked as a doctor in rural South Africa, with good supplies of both free condoms and affordable antibiotics to treat STI’s. We also had the usual AIDS awareness campaigns. It isn’t enough! Our antenatal HIV positivity rate reached 31% in 2000. Attitudes towards modifying behaviour were frighteningly fatalistic. Neighbours and family members were sometimes cast out or abandoned if they became ill and they were known to be HIV positive. Orphans were shunned. What is the incentive to come forward for testing in that scenario? You need something else… 5. ‘Evidence is coming out of Uganda that sexual abstinence and reduction of sexual partners can help reduce prevalence of HIV. Religions such as Islam, Christianity and Hinduism emphasise certain aspects of sexual abstinence and reproductive health. Religious organisations could therefore be used to help prevention alongside programmes to distribute condoms and treat sexually transmitted disease’ I think this line of argument speaks for itself! 6. ‘The Global Fund for AIDS, Tuberculosis and Malaria now controls most of the funding for tackling HIV and AIDS.’ If only this were true! Sadly, much of the money committed has not been handed over by most Western Governments, including the UK. The largest ‘donor’, the USA, is now potentially undermining the equitable aims of the GFATM, by insisting that it alone controls where two-thirds of its HIV aid spending goes to its chosen African and Caribbean countries (i.e. not India), and on its chosen model (Uganda), with a third stipulated to go to programmes promoting abstinence before marriage (The Lancet, 2003)… Well, wha’ d’ya know? Thanks, Dubya! To conclude: There are indeed many important lessons that India and the rest of the global community should learn from Africa’s painful experience of tackling HIV. Apart from highlighting the need to work more constructively with traditional healers on HIV prevention (including e.g. imaginative collaborations on DOT-HAART support), few are mentioned in this paper. References Matthew Flynn (2002) Cocktails and carnival. New Internationalist, 346: 16-17 Mina C. Hosseinipour et al (2002) Challenges in delivering antiretroviral treatment in resource poor countries. AIDS, 16 (suppl.): S177-S187 Paul Farmer et al. (2001) Community-based approaches to HIV treatment in resource-poor settings. The Lancet, 358(9279): 404ff Michel Kazatchkine (2002) ‘Antiretroviral treatment for HIV-infected patients in developing countries’ Keynote lecture at Sixth International Congress on Drug therapy in HIV Infection, 17-21 November 2002, Glasgow The Lancet (2003) A positive result for AIDS. The Lancet Editorial, 361(9357) 539 Competing interests:   JB is a Zambian doctor with first-hand experience of managing patients with HIV/AIDS in Africa since 1986 and in Scotland from 1999-2002. He is also a founding member of ImpAcTAIDS, the campaign for Improved Access to Treatments for AIDS in resource poor countries. ImpAcTAIDS is a registered Scottish voluntary organisation.
Out of Africa - evidence for effectiveness of abstinence 27 June 2003
Trevor G Stammers, Senior Tutor in General Practice St. George's Hospital Medical School, London Send response to journal: Re: Out of Africa - evidence for effectiveness of abstinence	When such a world authority as Prof. Malcolm Potts states that, “Evidence is coming out of Uganda that sexual abstinence and reduction in the number of sexual partners can help reduce prevalence of HIV” (1), and in the same BMJ issue an editorial also warns that “advocates of abstinence who say that condoms don’t work and advocates of condoms who say that abstinence does not work are both wrong”(2), it ought to make policy makers sit up and take notice. As an advocate of abstinence who also sees a role for condoms, I have, until now, been a voice crying in the wilderness as far as the UK is concerned (3,4,5). It is ironic that the above experts add their welcome voices to mine a week after publication of the Government’s Health Committee’s report on Sexual Health which foolishly maintains its ideological stance that “We see no benefit in preventative approaches based primarily around promoting abstinence.” (6) Truly, there are none so blind as those who will not see. 1. Potts M Walsh J Tackling India’s HIV epidemic; lessons from Africa BMJ 2003 326 1389-92 2. Ammann AJ Preventing HIV BMJ 2003 326 1342-3 3. Stammers T Doctors should advise adolescents to abstain from sex; for BMJ 2000 321 1520 2 4. Stammers T Lancet 2002 360 1792 5. Stammers T Abstinence under fire Postgrad Med J 2003 In press 6. Sexual Health Third Report of Session 2002-3 Vol I June 2003 p78 HMSO London Competing interests:   Trustee of Family Education Trust
HIV Treatments support HIV Prevention work 27 June 2003
Ade O Fakoya, Senior Programme Officer, International HIV Alliance ,Consultant Physician, Newham General Hospital The International HIV/AIDS Alliance Queensberry House 104-106 Queens Road , Brighton BN1 3XF Send response to journal: Re: HIV Treatments support HIV Prevention work	Dear Editor, I would like to thank the BMJ for its excellent edition highlighting some of the global issues of HIV. These are important for everyone. The article by Potts and Walsh made several good points, however it is disappointing that there still exists a large gulf between those calling for scaling up of anti-retroviral( ARV) treatment programmes and those who see the solution primarily focused on prevention. Far from it being individuals from the rich country lobby that are calling for treatments ( as stated in the paper) it is the many thousands of HIV positive individuals in poor countries who themselves demand equity of access to life saving therapies.As an example of this witness the treatment activism of TAC in South Africa. There are very many sound reasons why provision of ARV therapies within a framework of an expanded comprehensive response to the epidemic is important. Even putting the human rights and ethical arguements to one side, the infrastructure and economic development of many African coountries has been utterly devastated by this pandemic (1). The fabric of many societies is being eroded, and children ( as highlighted by another article in the same BMJ issue) are growing up as orphans with all the social and individual consequences this brings. Finally prevention work in isolation, without access to treatment means that individuals have little incentive to seek voluntary counselling and testing (VCT) and those identified become highly stigmatised. As we saw in the late 1980's and early 1990's people are reluctant to test if there are no available treatments.(2,3) Provision of low cost ARVs should therefore be viewed as part of the integrated response to the HIV pandemic; integrated with prevention and building on established treatment and care programmes and HIV mother to child transmission prevention programmes. Sadly the lack adequate funding for what will ultimately be one of the biggest threat to global security in the next few decades (4)means that the polarised debate on prevention versus treatment will continue. There should neither be Prevention programmes unlinked to ARVs treatments nor treatment programmes unlinked to prevention. references 1)AIDS drops life expectancy in 51 nations United Press International - Sunday, July 7, 2002 Ed Susman, http://www.aegis.com/news/upi/2002/UP020705.html accessed 26/06/03 2)Klosinski LE. HIV testing from a community perspective. JAIDS. 25 Suppl 2:S94-6, 2000 Dec 15 3)Anonymous. Don't take the test. The Optimist. Los Angeles: The AIDS Project/Los Angeles;1985:4 4)The Destabilizing Impacts of HIV/AIDS, Schneider M, Moodie M access at http://www.csis.org/africa/0205_DestImp.pdf,26/06/03 Competing interests:   None declared
Tackling India's HIV epidemic: Why Potts and Walsh should be ignored 29 June 2003
Rajan Gupta, Group Leader, High Energy Physics, Los Alamos National Lab Theoretical Division, Los Alamos National Lab, Los Alamos, NM 87545 Send response to journal: Re: Tackling India's HIV epidemic: Why Potts and Walsh should be ignored	I read the recent article "Tackling India's HIV epidemic: lessons from Africa" in BMJ volume 326, 1389-1392. While parts of the article present a reasonable point of view, there are many issues that will have a very significant backlash. I feel strongly enough to emphatically express my regrets that this article was published. The most important reasons why this article is very poorly informed about the social realities of India and why many of the policy recommendations will have a negative impact are the following: 1) CIRCUMCISION: It takes someone completely unfamiliar with India and the Hindu culture to even consider, much less recommend, circumcision as a policy or a strategy. A very significant way to distinguish between Hindus and Muslims in India (as painfully brought out during Hindu Muslim riots) has been male circumcision. This distinction is very deeply ingrained in the minds of people of both religions. Thus, the small (maybe 10-30% reduction in transmission rates compared to a factor of 2-3 due to the control of other STDs) role of circumcision in preventing HIV would not be sufficient to convince the majority of Hindu mothers or fathers to have their male children circumcised. The public outcry at such a recommendation, especially by "Americans", will further set back HIV/AIDS intervention very significantly, perhaps by years. 2) "CONFRONT LOBBYING FOR INCREASED USE OF ANTIRETROVIRAL DRUGS": The cost-effectiveness of prevention versus treatment is very well known and documented. The issue a policy maker has to consider is what fraction of a limited budget is spent on treatment and what fraction on prevention when there are 4 million HIV+ people in India and there is a wide range of estimates of growth, including those made by the National Intelligence Council. Do you abandon the 4 million? Do you give them band aids? Do you treat them as in Brazil or as in the US and the industrialized world? The lesson from San Francisco (which the authors should be very familiar with) is that PWHA are among the most effective change agents. Creating these change agents and removing the stigma associated with PWHA and HIV/AIDS requires access to treatment and social acceptance of HIV as another terminal but manageable disease. India is already suffering tremendously from many health and development crises, and failing in its HIV control because HIV+ people are considered immoral and thus marginalized. The recommendations made by you will only help the government shrug its responsibility by quoting eminent scholars who doubt the efficacy of treatment. My question to you is -- Why does the medical and public health establishments in the US not unite and fight against large pharmaceutical companies that are keeping the cost of these drugs high, rather than make recommendations that the authors would not adopt for the US? 3) "RELIGIOUS LEADERS": All religious leaders in India - Hindu, Christian, Muslim - have been advocating abstinence and upholding high moral standards through time, irrespective of HIV. I have not met any religious leader, outside of fringe groups, who do otherwise in public, even though many lead very interesting sex lives. In fact they are some of the most vocal proponents of the morality issue that continues to fuel the stigma. What message would the authors like religious leaders to give to their congregation? In my opinion, one way in which religious groups can make a substantial positive contribution is to start care centers for HIV positive people. It would have been far more constructive if the authors had recommended this latter possibility. 4) "URBAN VERSUS RURAL": you seem to indicate that risk begins once people migrate from villages to the anonymity of urban life. You say India remains a traditional society. But what are the patterns of sex and sexuality in this "traditional" society? Rural India enjoys and suffers sex - the details would fill volumes - much of which you would classify as very high risk sex. In short, the risk of HIV is very large once the infection enters any community in India! This is another reason why your recommendation for targeted intervention would fail and is failing in both India and Africa. 5) "PRESCRIPTION REGULATIONS IN RURAL INDIA": I wish there was an enforcement of prescription regulations in rural India or anywhere for that matter! 6) "TARGETED INTERVENTION". Targeted intervention as a policy has not been successful even in the US. Such policies have failed to stem the tide in Africa. I include a more general argument below on why the window of opportunity for it has passed in India. Here, I state my reasons for why it should not be recommended even in the US, nor is it working in practice. The label of HIV as a gay disease set back the US response by years and even now a significant fraction of the public makes that connection and therefore denies risk to them or to their family. The rise of infections in the 15-24 year old heterosexuals in the US shows that the infections are spreading in this so called "low risk" group. The advocacy for a nationwide school education program, which targets all students in the US, is certainly a universal approach and not one based on immediate high risk behavior or group. I will now spell out in some detail why we should not think in terms of "targeted intervention" in India. I have also made this case to NACO (National AIDS Control Organization) recently. I believe that as a National Policy the window of opportunity for targeted intervention has passed. The National Policy should be aimed at the entire population for the following reasons. Targeted intervention as a policy relies on four fundamental concepts: 1) The target populations are small 2) The target populations are well defined 3) These target populations accept their identity and are recognized by it 4) The infections are still mostly contained in this population I believe that with respect to HIV/AIDS and the current level of spread of HIV/AIDS, these four conditions no longer apply in India. 1) THE HIGH RISK GROUPS ARE NOT SMALL commercial sex workers = 2-8 million (or more if you count casuals) men who have sex with men = (assuming 5% of adult, sexually active males ~ 15 million) injecting drug users = my guess is about 1 million street children/child labor = 40-50 million truck drivers, cleaners,.. = 3-5 million migrant labor = over 200 million (agriculture and industrial) clients of sex workers = (excluding the above groups) ??? and so on .... = partners of the high risk groups THUS, EVEN BY NACO COUNT/LABEL HALF OR MORE OF THE SEXUALLY ACTIVE POPULATION IS ALREADY PART OF THE VERY HIGH RISK GROUPS 2) THESE TARGET GROUPS ARE NOT WELL DEFINED: Many truck drivers/assistants work in the trucking industry for only a few years or do other work which they accept as their primary identity. Many sex workers are also wives/husbands. Street kids and child laborers are just children. A large fraction of migrant labor is seasonal or does migratory work for short periods of time (few months) only and sporadically. Most cities and villages have sex workers, but very few live and work in well defined areas or brothels or would accept the label of sex-workers. (I could give many more such examples.) 3) Of these groups, the majority of the CSW, MSM, IDU, vulnerable children, do not have an identity and would certainly not accept or respond to labels we assign them or would come forward if we call them using these labels. Also, each of these categories are stigmatized, so labeling them has added to the problem. PEOPLE HAVE MULTIPLE IDENTITIES AND ARE LEAST LIKELY TO ACCEPT IDENTITIES THAT LABEL THEM AS HIGH RISK AND ARE STIGMATIZED. 4) The infections have spread out of these high risk groups as data from ante-natal clinics show. I doubt if there is any village in India that does not have a cohort of migrant workers that has lived a significant fraction of the last ten years as a migrant worker. They pose a risk to their whole community, and not just their immediate families. Given the risk factors, the demographics and the current level of spread of HIV, the national policy has to be aimed at the full population. The perception of risk by the public, based on my interactions with thousands of people, still is that HIV/AIDS is a problem of the immoral -- the high risk groups. People have not come to understand how large this population is nor to accept how many people at some time in their lives have risky sex, or come in contact with blood or needles or medical instruments that are infected. The concept of targeted intervention is important in the implementation. The most effective workers within these high risk groups are peer educators, peer counselors, and peer health workers. The ability of PWHA to act in these capacities requires that treatment be a very important and significant part of the policy. The next most successful are NGOs with a holistic portfolio who integrate HIV/AIDS work into their activities. The funding of NGOs should reflect this. This distinction between policy and strategy for implementation, especially with respect to targeting high risk populations, should be clarified otherwise denial, and ignorance of risk will continue and the infections will continue to spread. I hope that the above arguments convince the authors of the need to reconsider their arguments and recommendations. I sincerely hope that more thoughtful and empathic people design and implement policy in the global fight against HIV/AIDS. Sincerely Dr. Rajan Gupta Competing interests:   None declared
Why India should disregard the advise of Potts and Walsh 30 June 2003
Joe Thomas, International Centre for Health Equity Inc Melbourne, Australia. 3141, Mridula Bandyopadhyay Send response to journal: Re: Why India should disregard the advise of Potts and Walsh	Joe Thomas. MSc. Ph.D Director, International Centre for Health Equity Inc. Melbourne, Australia Mridula Bandyopadhyay. MSc. Ph.D Lecturer, Key Centre for Women’s Health in Society School of Population Health The University of Melbourne Victoria 3010 Australia Malcolm Potts and Julia Walsh’s article (2003;326:1389-92) Tackling India's HIV epidemic: lessons from Africa ? is a timely contribution to the much needed education and debate on HIV prevention in India. However, these are the types of advice the Indian policy makers should precisely disregard. Although it may not be apparent, looking at the timing of the article, it appears that the authors are expecting to achieve two objectives: a) the authors are trying to position themselves as the lead advisors of the proposed Bill Gates Foundations multi million India HIV initiative; b) to take a gentle swipe at the Indian manufactures of generic anti retroviral medications. Besides, this article should also be criticised on grounds of the authors’ lack of empirical understanding of the social determinants and consequences of HIV infection in India. In addition, they also demonstrate a patronising attitude and lack of appreciation of the intellectual leadership of Indian researchers and policy makers in addressing HIV/AIDS related issues in India. In this context, it is essential to closely examine the conceptual poverty of the assumptions put forward in the argument of Potts and Walsh. A) While prescribing the involvement of “high risk groups” in all phases of the programs, unfortunately Potts and Walsh demonstrate how divorced they are from the current literature or thinking about the conceptualization of risk and risk behaviours in the context of HIV infection. To state bluntly, there are no ‘high-risk groups’ in India. Only, there are people practicing ‘high-risk behaviours’. Those who are familiar with the ground level, lived experience, or have access to large amounts of empirical data on the complexity of HIV infection in India, would know that mathematical models might not be able to precisely predict the cultural and social complexity of risk and risk behaviours in India. Further those who are familiar with the social epidemiology of HIV infection in India would also agree that, currently India is experiencing an aggregate of multiple epidemics of HIV in different geographical settings and among people with different types of risk behavior. Hawkes and Santhya (2002) observed that the number of cases in women infected through heterosexual transmission within marriage is increasing. Seroprevalence of 13–24% HIV have been reported among female STD clinic patients who are not sex workers. For many monogamous women in India, marrying a person who is practicing high-risk behavior is the source of HIV infection. B) The focus of intervention should not be on high-risk groups but rather on people and communities who are vulnerable to HIV infection. The pattern and process of their vulnerabilities should be the target of intervention. Involvement of vulnerable population should be welcomed in all aspects of intervention programs. In the past interventions targeted at ‘high risk behaviour groups’ was one of the major source of HIV/AIDS related stigma and discrimination, leading to a critical barrier in developing effective HIV prevention programs (UNAIDS 2002). C) Focus of interventions should be on evidence based prevention programs rather than on economic rationalism alone. Apparently Potts and Walsh’s understanding on the impact of poverty as a cause and consequence of HIV infection is too narrow. Poverty reduction should be one of the overall goals of HIV prevention in developing countries as HIV infection could lead to poverty. People living with HIV/AIDS in India are one of the key resource group who could be marshalled to fight against HIV. Greater involvement of people living with or affected by HIV/AIDS (GIPA) have been universally accepted as key principle of HIV prevention (UNAIDS 1999) D) There is a need to secure adequate supplies of condoms, antibiotics and antiretroviral medication as part of HIV prevention programs. Potts and Walsh have correctly observed that India has the advantage of a large, competitive, and technically competent pharmaceutical industry, and the government is subsidising distribution of condoms to low-income families. This subsidy should be extended to antibiotics for controlling sexually transmitted diseases and antri- retroviral as well. The international donor community should ensure that priority is given to funding condoms, antibiotics and antiretroviral medications. Specific resource allocation for enhancing access to care and treatment for people living with HIV/AIDS should be one of the critical criteria for accepting international donor assistance. E) A careful balance needs to be maintained in investing in large- scale projects as well as pilot projects. While national level larger scale evidence based projects are to be priority. Pilot projects for enhancing access to care and treatment, reducing stigma and discrimination in various settings, and projects to reduce poverty among the people living with HIV are also in urgent need. Indian policy makers and program managers should accrue skills through pilot projects, as large-scale projects often require expensive international management, technical assistance, and sacrifice of project autonomy. F) The advise to include traditional health practitioners in control programs should be welcomed at all levels of HIV program management and intervention development. G) International donor agencies should acknowledge the opportunity cost of HIV prevention programs. Quite often resources committed face unreasonable delay in actual implementation of interventions. Thus, there is a need for greater appreciation of the opportunity cost of such delays in intervention developments. H) While large international meetings waste resources, there is definitely a need to develop national level meeting to generate consensus, sharing of experiences, building coalitions and networks. I) Furthermore, advocacy for increased use of generic antiretroviral drugs is essential in India. The quality of life of people living with HIV in rich countries has improved because of antiretroviral drugs. However, Potts and Walsh fail to present a compelling argument against facilitating such benefits to people living with HIV in India. The mindset of people that argue against enhancing access to care and treatment for people living with HIV/AIDS in India is set in a colonial time frame, fraught with racist superiority. Such arguments should be denounced for what they are worth. In essence, India has the technical ability to produce generic antiretrovirals which should be widely encouraged and should be legally protected from international trade bullying. An active program to enhance the skills of health care providers should be a priority with much needed research and local data on effective monitoring of the progression of HIV disease. There is no empirical data to substantiate the argument “that money spent on antiretroviral drugs is money removed from prevention, and vice versa”. It is just a patronising assumption. Treatment is prevention. “The people who benefit will probably be those who are most educated or have access to specialist care” is not a valid argument against providing ARV treatment for them. The much-needed leadership of people living with HIV comes from these groups itself. J) One of the most culturally insensitive recommendations of the authors’ is their advocacy for massive male circumcision in India, could be pardoned given the authors’ total lack of knowledge about the Indian sub-continent. Besides, empirical evidence on the efficacy of male circumcision to slow transmission of HIV is also sketchy; and advocating for male circumcision in the Hindu cultural context shows a total lack of understating about the ‘cultural meaning of circumcision’ in India. Recommending such solutions broadcast the authors’ ignorance about the complex history of Hindu Muslim relations in the Indian sub-continent. Or is it another patronising statement from the authors? In our view, India should seek local solutions for this global problem. Capacity building of Indian health care providers and enhancing the intellectual leadership of Indian commentators and HIV researchers should be considered as a top priority. Potts and Walsh’s article is a timely reminder of the issues at hand. However, the solutions they are providing are not evidence based and smacks of patronising assumptions. One would expect a much more rigorous analysis and argument presented in the BMJ. Competing interests: Joe Thomas is the moderator of AIDS-INDIA e FORUM. An electronic forum for information and communication on AIDS related issues in India. http://groups.yahoo.com/group/AIDS-INDIA References: Potts M, Walsh J. Tackling India's HIV epidemic: lessons from Africa. BMJ 2003;326:1389-92. S Hawkes, K G Santhya, Diverse realities: sexually transmitted infections and HIV in India. Sex Transm Infect 2002;78(Suppl I):i31–i39 UNAIDS 2002. Live and let live. A global campaign to reduce HIV/AIDS stigma and discrimination UNAIDS 1999. From Principle to Practice. Greater involvement of people infected or Affected by HIV/AIDS Competing interests:   Joe Thomas is the moderator of AIDS-INDIA e FORUM. An electronic forum for information and communication on AIDS related issues in India. http://groups.yahoo.com/group/AIDS-INDIA
Scientific Institutions being co-opted to benefit commercial interests and political agendas by infl 6 July 2003
Purushothaman Mulloli, General Convenor, Jackindia New Delhi - 110021 Send response to journal: Re: Scientific Institutions being co-opted to benefit commercial interests and political agendas by infl	Dear Editor, This is regarding the article "Tackling India's HIV epidemic: lessons from Africa", by Drs Potts and Walsh, published in BMJ volume 326, 1389- 1392, June 21, 2003. This paper stands discredited for the reason that its fundamental premise – the scale of the HIV epidemic in India – is based on unsubstantiated statistics. A more serious accusation is that its authors stand guilty of giving scientific credibility to misconceptions being created by agencies with political and commercial agendas. It is a shame to see scientists from respected institutions making themselves cheaply available to serve various vested agendas – despite the fact that that they, more than anyone else, would know the devastating impacts of such scientific fallacies. Drs Potts and Walsh state that the number of HIV infections in India would number 20 to 25 million by the year 2010. They have derived this figure from a 2002 paper by National Intelligence Council (CIA), USA, “The next wave of HIV/AIDS”. The CIA paper claims to have arrived at this figure by conferring with “the Intelligence Community” and “several leading experts from outside the Intelligence Community as part of its effort to seek out expertise from inside and outside the government”. The list of the experts mentioned in the CIA paper do not include even a single source of information or data from within India (with all of them hailing from American Institutions) – nor does it makes any mention of the data from which these experts drew their conclusions. If the source/evidence is not disclosed, the data cannot be accepted as reflecting any reality and such a practice is globally understood as invalid for the quotation of statistical statements. Such figures are therefore to be rejected as they may be pushed into the field for reasons of vested interest. Dispite a billion strong population, India has of one of the best scientific surveillance and data collection systems globally and it is disturbing to see credible agencies and institutions discrediting official Indian data so freely and blatantly – without feeling the need to substantiate their reasons for doing so. This kind of activity is certainly not science. Last November, when when Bill Gates began issuing statements quoting CIA’s HIV figures – as a build up to his AIDS philanthropic visit to India, we questioned the Indian government about the veracity of these figures. Caught in the media glare and public demands for facts – the Indian government denied that it had anything to do with the CIA figures and they did not support the same. Bill Gates involvement with CIA figures goes significantly deeper to the extent that his foundation funded the CIA report – just as it has also funded this study by Dr Potts and Dr Walsh. It is obvious enough to us that there are huge commercial interests and political agendas to be served by inflating India’s HIV figures. The fact that CIA’s figures for India are being quoted and re-quoted now globally by leading International NGOs like Amnesty and prominent personalities like US Ambassador Blackwill, Bill Gates, Richard Gere etc. is a matter of alarm. Even more disturbing is to see these figures being quoted in scientific papers – and being published in a magazine like the BMJ. There is no value in drafting a country specific paper attempting to analyze and prioritize “cost effective” interventions and other prevention strategies if the basic information on a disease is invalid. According to National AIDS Control Organization (NACO), the Indian agency officially mandated to carry out HIV surveillance, the HIV rates in India have stayed relatively stable at under 4 million, over the last four years. As NACO states, ““The estimates for 1998, 1999 and 2000 were 3.5 million infections, 3.7 million infections and 3.86 million infections respectively. The number of infections can therefore be put at 0.11 million (3.97 – 3.86 in 2001 as compared to 0.16 million (3.86 – 3.7 in 2000). This shows that while the epidemic is still spreading in the country, there is a gradual decrease in new infections. Over a period of time, the new infections may reduce to a negligible number, which is an indicator of the plateauing of the epidemic.” NACO uses the ‘Sentinel Surveillance System’ to collect its HIV data – a system that has been designed by leading international epidemiologists, including those from Monitoring of AIDS Pandemic (MAP), and is being promoted globally by the WHO as one of the most scientific methodologies for HIV surveillance. This system has been established nationwide in India with the help of the best in the field, and NACO’s HIV estimates thus derived have been further subjected to close scrutiny by a panel of leading epidemiologists of the country and outside, as well as MAP. The UNAIDS also uses NACO’s Sentinel Surveillance System figures for India in its global reports. Although the “future projections” made by the UNAIDS talk of 8 – 10 million HIV cases in India by 2010 – even these unreasonably inflated figures fall far short of those made by the CIA paper One wonders what sources the CIA’s “experts” might have relied on arrive at such radically inflated data when the Sentinel Surveillance figures reflect no sign of an escalating epidemic. Despite requests by JACKINDIA the CIA has not disclosed to the Indian public the evidence / database used by concerned CIA experts to arrive at their conclusions. Statistics provide ‘scientific rationale’ for various government initiatives and polices, including public expenditures, drug procurement and distribution policies, investments on drug research and human trials etc. Exaggerated projections on a single disease can have far reaching negative impacts by distorting health care policies and expenditure by encourage unwarranted diversion of funds, besides instigating a social / economic and political crisis in this country. They can also provide justification for direct involvement of foreign agencies in domestic issues, influence the global community to act against our interests – while expanding the scope and freedom for military, political and commercial activities of vested political and market interest groups. We request the scientific community to take care before it wholesale accepts the claims of ‘experts’ – particularly those of “intelligence agencies” of one country who are not mandated to carry out disease surveillance in other countries. Yours sincerely, Purushothaman Mulloli General Convenor Jackindia Competing interests:   None declared
Global Failures and Local Successes in HIV prevention 9 July 2003
Daniel Low-Beer, Cambridge University Health, Cambridge University Sidney sussex college, sidney st., Cambridge University, Cambridge CB23HU, UK. Send response to journal: Re: Global Failures and Local Successes in HIV prevention	Global Failures and Local Successes in HIV prevention Editor-Your recent articles placed an important emphasis on HIV prevention,(1) but we need to learn much more clearly from local situations where HIV prevention has worked. There was optimism for HIV prevention in the early 1990s similar to today, with HIV declines at national level in Africa (Uganda) and Asia (Thailand). Uganda still provides data which are relatively clear and conclusive, yet there remains confusion over its interpretation. The declines in HIV prevalence and incidence (among pregnant women, military, population surveys and cohorts) are associated with a 65% decline in casual sex in comparable surveys, 1989-95.(2,3) Furthermore a four country comparison showed casual sex was 60% lower in Uganda in 1995 than in Kenya, Zambia and Malawi, while condom use was similar.(3) These changes were not shown by UNAIDS reports, nor does the BMJ article build on them.(1) Fortunately they have been consistently highlighted by a few researchers who kept details of the early data which was not publicly released.(3,4,5) Without greater clarity, it has been difficult to transfer lessons to the global level. Successes in Uganda or Zambia were not based on a focus on high risk groups, STD treatment, HIV testing (at low levels before 1995) or widespread provision of condoms.(1) There was a more targeted approach based in STD epidemiology in Kenya and other countries where HIV did not decline in the 1990s. Uganda had a broad based focus on general sexual behaviour recommending “zero grazing”, with direct discussion and warning about AIDS at all levels of society, and local AIDS diagnosis (largely stopped elsewhere after 1995). This is reflected in the higher levels of communication about AIDS and people with AIDS through social networks in Uganda,(5) and distinctive changes in sexual behaviour indicators. Uganda was “awash” with local programs and NGOs,(1) with a focus on care. However they may represent a more valid response than the large scale, systematic development projects advocated at global level, for example by the Gates Foundation in India, in South Africa with loveLife, and their expensive Global Blueprint.(1) These often displace a community based approach to HIV, with a set of external priorities. Global funding is important, but the crucial Uganda program, 1987-92, had a total budget of $21,676,000 US for five years (under 1 billion $US if applied to Africa). Global policy needs to learn much more from local, national situations rather than the reverse, if HIV prevention is to be successfully scaled. 1. Potts M., Walsh J. Tackling India’s HIV epidemic: lessons from Africa. BMJ 2003;326:1389-1392. 2. Asiimwe-Okiror G., Musinguzi J., Opio A., Low-Beer D., Stoneburner R. Declines in HIV prevalence in Uganda pregnant women and its relationship to HIV incidence and risk reduction, XI International Conference on AIDS, Pub. Abstract MoC905 1996. 3. Stoneburner R, Carballo M. An assessment of emerging patterns of HIV incidence in Uganda and other East African countries. Arlington, Virginia: Family Health International 1997. 4. Low-Beer D, Stonburner R. Evidence of distinctive communication channels related to population level behaviour changes and HIV prevalence declines in Uganda, XIV International Conference on AIDS, Pub. Abstract WePeD6263 2002. 5. Low-Beer D, Stoneburner R. In Search of the Magic Bullet: evaluating and replicating HIV prevention programs, New York, Kaiser Family Foundation 2001 (available at www.kff.org). Competing interests:   None declared
Culturally Inappropriate Preventive Measures 10 July 2003
Santhanam Sundar, Consultant Oncologist Nottingham City Hospital, Nottingham Send response to journal: Re: Culturally Inappropriate Preventive Measures	Dear Editor Potts and Walsh are quite right in recommending investments only in AIDS projects that can be fully implemented (1). But they contradict themselves when they suggest male circumcision as potential primary prevention measure. Circumcision is often associated with religion in many parts of the world, and more so in India where invariably all circumcised men are Muslims. So Circumcision is unlikely to be a culturally acceptable preventive measure in India. Moreover Circumcision is not going to be a cost effective prevention measure. It would be a logistical nightmare to train health workers and provide proper facilities for circumcision across the wide geographical area of India. Tackling India’s AIDS epidemic requires the input of ground level workers rather than a pure ‘top down’ initiative. References: 1. Potts M, Walsh J. Tackling India's HIV epidemic: lessons from Africa. BMJ 2003; 326: 1389-1392 Competing interests:   None declared
Tackling India’s HIV epidemic: lessons from Kerala 19 July 2003
Stephen M Clift, Professor of Health Education Canterbury Christ Church University College, CT1 1QU Send response to journal: Re: Tackling India’s HIV epidemic: lessons from Kerala	The article by Potts and Walsh appeared shortly before I embarked on a three-week study visit to Kerala and Tamil Nadu to learn more about health problems in India – and I read it with considerable interest. However, after visiting the Support Unit of Kerala State AIDS Control Society in Trivandrum, it became clear that the lessons to be learned from two decades of preventive work around the world have long been absorbed into the strategies of the Indian National AIDS Control Programme, and the work of State AIDS Control Societies throughout the country. The need to gather accurate epidemiological data to guide interventions, to target and actively involve high risk groups, to tackle treatable STDs and promote condom use, are all recognised in major strategy documents and implemented in innovative and well evaluated programmes on the ground. Further issues, which Potts and Walsh neglect to mention, such as making services more accessible to marginalized and stigmatised groups, promote empowerment and health seeking behaviour among potentially vulnerable groups and advocacy work with health professionals to address misconceptions and prejudice are also priorities in the preventive effort. I was very impressed with both the documentation I was given in Trivandrum and the work of projects with sex workers and MSMs I saw in projects that have been going on for nearly five years, and Potts and Walsh would have done well to have at least acknowledged the fine work that is going on in India. Two specific points made by Potts and Walsh deserve comment. 1) They suggest that 95% of India’s population cannot afford condoms, given income levels in India and their cost. However, in the specific case of men using the services of sex workers, the more important issue is the cost of condoms relative to the cost of buying sex, and the need to keep the additional cost low. In Trivandrum, four categories of sex worker are recognised: street workers, hotel based workers, family girls (who go from door to door selling goods, but actually sell sex) and call girls. In the case of hotel workers, prices charged for sex range from 200 to 700 Rupees (between £30-£10 approximately), and a scheme has been developed whereby hotel staff (e.g. receptionists) can buy condoms at cost price which they can sell singly to clients for 10 Rupees (i.e. approximately 7 pence) and make a small profit. 2) Potts and Walsh also suggest that ‘Attention needs to be given to the increasingly strong evidence that male circumcision slows transmission of HIV’. This is presumably good news for India’s Muslim population, but the idea that efforts might be made ‘to offer circumcision to Hindu men’ is frankly laughable. Has anyone ever seriously suggested that we might tackle the continued growth of HIV infection among gay men in this country by this means? Given the current concern about the general deterioration in the sexual health of the UK population, I left India feeling that the BMJ might consider publishing an article with the title: ‘Tackling the UK’s HIV epidemic: lessons from Kerala’! Competing interests:   None declared
Controversial Article 9 September 2003
Dr. Vikas Dhikav, Resident All India Institute of Medical Sciences, New Delhi-110029 Send response to journal: Re: Controversial Article	Sir, I have gone through all the responses and two letters that have been published in BMJ in response to article by Potts and Walsh. I guess, this has been one of the most controversial articles that I have seen in BMJ in recent times. This is because, I have noticed that almost every paragraph of the article has been criticized or commented upon in a negative way. Some one has said, why picture? I feel too that was unnecessary. "Circumcision for Hindu men.." That’s awkward too. Another important thing which the article says that, "In India, most rural practioners have formal training in Ayurvedic medicine..." This is incorrect because, most of the rural doctors here in India are quacks, they practice without license and are forbidden by the Indian Medical Council Act of 1956. They are not allowed to prescribe allopathic or modern drugs leave aside the antibiotics, which Potts and Walsh have talked about. This reminds me that the article has been written superfluously and flippant statements have been made at places. However, I do not completely agree with Mridula when she says that the authors are unaware about the ground realities of India. Authors have hinted at places about the situations and practices prevalent in this part of the world. However, comparing India with Africa is inappropriate in many ways. Another controversial statement of the article is that the authors have said that the traditional doctors should be made a part of healthcare and may be utilized in fight against AIDS. However, here in India, they prescribe western drugs, rob patients and make easy money. That is why; the law does not recognize them as legitimate doctors for practicing medicine anywhere in India. Authors should have been more specific as to which aspect of the AIDS prevention; can their services can be useful? How can they be inducted in mainstream considering the ground realities and the view the law upholds? Authors seem to be right on their views about the heterosexual mode of transmission; this is because this is the dominant mode. At best, the figure of homosexuals in India is not beyond 5 millions. Having said so, this does not mean that the prevention strategies should not be focused upon them. However, the potential for prevention is much more for the heterosexual route. I wished that the authors did a bit of cost analysis and analyzed the economical aspects of the problem in subcontinent as well; rather than making controversial statements. I assume, the editors would remain aware in future not to publish any material whose credibility has not been properly and fully established. It would not be a bad idea in this regard to send such articles to someone from that nation or region for peer review in addition or over and above the routine peer review process, which BMJ routinely follows. Sincerely Yours, Dr. Vikas Dhikav, All India Institute of Medical Sciences, New Delhi-110029 Competing interests:   None declared