Sunday, September 7, 2014

Revised History of HIV in Kenya – Part VII – Health Facilities

Part VI explored the possibility that family planning and Sexually Transmitted Infection (STI) services may have been provided in health facilities that would later be deemed unsafe in the context of HIV, involving reuse of syringes and other equipment with inadequate or no sterilization. Many determinants have been identified for STIs throughout the twentieth century, all over the world. They include poverty, poor education, unemployment, ‘promiscuity’ (Meheus, 1974), low prevalence of contraception and others. STI prevalence tended to be higher among men than women, high in both urban and rural areas, higher among unmarried than married people (Hopcraft, 1973) and fairly evenly distributed around a country such as Kenya. In contrast, HIV is more likely to be associated with relative wealth, better education, employment, proximity to roads and other infrastructure, higher use of contraception, urban dwelling, marriage and others. More women than men are infected, associations with sexual behavior considered unsafe are often not very strong and prevalence is unevenly distributed, with a few hotspots in Kenya and many ‘coldspots’. One might logically conclude that, while HIV can be transmitted sexually, it is often transmitted in other ways, and that is why patterns of infection for HIV differ so much from patterns of infection for other STIs.

However, there are important overlaps in these patterns of STI and HIV infection. For example, HIV prevalence was found to have reached 4% among Nairobi sex workers in 1981 and increased to 61% by 1985; this was established by retrospectively testing stored blood samples (Piot P, 1987). Females infected with non-HIV STIs in the past were generally found to be engaged in sex work or had a partner who had visited a sex worker. Prevalence of STIs was often high in certain occupational groups, such as transport workers, soldiers and those employed in extractive industries. As a result, these and other groups had long been targeted by STI eradication programs; sex workers had also been targeted by various family planning initiatives. This suggests that those facing high risks for infection with STIs, or assumed to face high risks, may have had increased non-sexual risk of being infected with HIV once that virus began to spread (having established itself several decades before). Although HIV prevalence went up to 81% among sex workers in Nairobi, it peaked in 1986 and declined steadily for nearly 20 years without any reasonable explanation being found for this trajectory (Kimani J, 2008). Oddly enough, neither Piot et al nor Kimani et al consider the very strong possibility that sex workers (and members of other targeted groups) were systematically infected with HIV through unsafe healthcare until this risk was eventually recognized (or perhaps changes in practices reduced the risk of transmission without anyone noticing the impact this was having on healthcare transmission until much later?).

In the early 80s, no precautions had been taken to prevent the transmission of blood-borne viruses such as HIV in health facilities, as the virus had only just been discovered. Throughout the 80s, as it became apparent that health facility transmission was (or could become) a significant risk, certain measures were taken to improve safety. But the changes would not have been adequate to eliminate transmission altogether. In the 90s, as mentioned in Part III, access to health facilities declined, which may have inadvertently protected many people from infection; HIV incidence in the general population peaked some time in the 90s, at a time when visitor numbers to health facilities would have been falling as a result of increasing poverty, the introduction of ‘user fees’, cuts in service provision and other factors. Sex workers and others thought to be ‘promiscuous’ must have faced a very high risk of being infected with HIV in STI and family planning facilities, although the risk must have decreased considerably some time in the 80s and continued to decline, without ever being completely eliminated.

As for those not considered to be so ‘promiscuous’, they would also have faced high risks in general health facilities. Family planning and STI facilities were often integrated into general healthcare services. Women attending antenatal care (ANC) services and giving birth may have faced higher risk than others (aside from sex workers and other groups targeted by STI and family planning programs). This makes it less surprising that very high HIV rates were found in ANC clinics from the late 80s onwards. HIV prevalence is often highest among women of childbearing age. While these same women may (or may not) be more sexually active that others among whom HIV prevalence is lower, they clearly face increased non-sexual risk of infection with HIV at ANC clinics that are not particularly safe. Family planning services were promoted widely, often aggressively promoted, and not just to those thought to be ‘promiscuous’. Family planning, ANC, contraception and even general health services tend to be more accessible and more utilized in urban areas, by wealthier, better educated people (Hopcraft, 1973), the very groups found to be more likely to be infected with HIV. So people with HIV are more likely to have faced various non-sexual risks, whatever about their sexual risks. Why do UNAIDS and the HIV industry seem only to consider their sexual risks? Piot et al and Kimani et al are not exceptional in completely ignoring the possibility of massive levels of healthcare transmission of HIV; the entire industry has grown out of denying that unsafe healthcare could have played a part in transmitting a virus that is a lot less efficiently transmitted through heterosexual sex.

For a long time in Kenya (and other developing countries), family planning had been seen as a means of ‘promoting economic development’, as well as ‘improving maternal and child health’. It wasn’t just highly intrusive and aggressively promoted because it was seen as beneficial to Kenyans and other Africans, but also because it was seen as a means of reducing population growth and averting an eventual global shortage of food, water and vital resources. In the same way that preventing and treating diseases in developing countries was a way of ensuring a ready supply of cheap labor in resource rich countries, family planning was seen as a way of controlling birth rates and population increases beyond what was needed for labor. For many NGOs operating in African countries now, family planning is development; and ‘maternal and child health’ consists of, pretty much, family planning. It is seen as something of a truism that maternal and child deaths can be reduced most readily by reducing fertility rather than, say, improving conditions in hospitals and elsewhere.

A 1973 paper reveals something about conditions in STI clinics in Uganda (Arya, 1973). For a start, it is pointed out that over 90% of the population lives in rural areas. Therefore, most of the population’s health needs are catered for by rural health centers, dispensaries and other minor facilities, staffed mainly by auxiliaries, rather than by more highly trained professionals. Whether it is because STIs were common or because the colonial and post-colonial administrations were exceptionally interested in them, Arya argues that “venereal disease played an important role in the organization of the medical services in Uganda in the beginning of this century.” Mulago Hospital, started in the second decade of the 20th century as an STI clinic, became and remains the largest referral hospital in the country. This is similar to Kenya, with specialist STI services being available in Mombasa and Nairobi for many decades. Health expenditure is low, estimated at around one dollar per year per person in the mid 70s, but basic health services were provided free of charge. Arya alludes to the lack of success of most STI programs, in both developing and rich countries, in bringing these diseases under control; he suggests that there are other diseases that may be in more urgent need of attention. Arya also notes that private practitioners provide STI services, mainly in larger towns, and that the quality of these services is unknown.

Arya published a paper in 1976 about the role of medical auxiliaries in STI control in developing countries (Arya & Bennett, 1976). In common with some other authors, Arya and colleague draw attention to the high disease burden faced by developing countries, coupled with the scarce resources, human, financial and material. These are particularly acute in rural areas, where most people live, but where well qualified professionals are reluctant to work. The authors also feel that STI services are mismanaged to the extent that they may be causing more problems than they are solving, with high prevalence resulting from “inadequate treatment, improper treatment or no treatment at all”. They mention high treatment default rates, find the contribution of private practitioners to STI control ‘questionable’ and conclude that the overall quality of services is poor. Diagnoses were unreliable (Burney, 1976), patients were receiving repeated injections of small doses of penicillin, which increased resistance, etc. Another paper notes the injection of large volumes of penicillin in some countries, which is likely to have involved the use of glass syringes and reusable needles in those days (Meheus, 1974). Contact tracing was generally beyond the capacity of STI service providers. Arya and Bennett recommend that medical auxiliaries specialize in STIs and that their training includes “knowledge of the local socio-cultural factors which largely determine traditional sexual mores” and note that STI patterns “differ from those in the western nations and may even vary from one area to another within a country”.

The papers cited above and in Part VI give a few insights into what things were like in terms of STI programs in Kenya and Uganda in the 1970s. Many of those said to be dying of ‘slim disease’ in Uganda in the early 1980s could have been infected with HIV as long as ten years before. If the rate of new infections peaked in the late 1980s, transmission would have been increasing throughout the 1970s, reaching its peak in the late 1970s. Why incidence peaked and then declined is another story. It may have had something to do with the 1978-1979 war with Tanzania (wars tend to be periods of low HIV transmission (Gisselquist, 2004)), the civil war from 1981-1986 or, much more likely, a combination of factors. Incidence began to increase a few years later in Kenya, perhaps in the mid 1970s, reaching a peak in the early 1990s, as discussed elsewhere. However, incidence started to increase earlier among certain groups, such as sex workers, transport workers and others who, significantly, had been targeted by STI eradication programs for decades. Incidence also would have peaked and begun to decline earlier in these groups.

Conditions in Kenyan health facilities in the 1970s, especially those providing STI and family planning services, were poor. If a blood-borne virus were to establish itself in one or more of these facilities, there would have been plenty of scope for it to be transmitted widely, not just among populations aggressively targeted by various health programs, but also among those requiring other health services, such as antenatal care. The risks of widespread transmission of HIV in health facilities were not recognized for a number of years and many more years had passed before any of these risks were addressed (some have yet to be addressed). But western HIV awareness campaigns were hijacked long ago by various parties who wished to present the virus as one transmitted almost entirely through ‘promiscuity’, and who wished to deny the possibility of transmission in health facilities. Because most of those infected in African countries were heterosexual, a different story about transmission needed to be created. Unfortunately, the same campaigns and strategies were exported from wealthy countries, where transmission was almost entirely a result of male to male sex or intravenous drug use. These campaigns were supremely unsuccessful in Kenya, but this was blamed on the failure of individuals to change their sexual behavior, rather than on any non-sexual mode of transmission.

If HIV transmission in health facilities and through other non-sexual modes continues, the virus will not be eradicated. More poignantly, if health facility transmission had been addressed in the 1980s, when it was realized that this was a very efficient mode of transmission, the virus would never have infected so many people. Some of the worst epidemics in the world only got going in the late 1980s or early 1990s, such as Zimbabwe, Botswana, South Africa, Swaziland, Mozambique and others. Many of the biggest players (bureaucrats, politicians, publicists, academics, industrialists, etc) currently driving the HIV industry have been in the business since the 1980s. Must Kenyans and other Africans wait till these ‘experts’ are gradually replaced by more enlightened personages? It is to be hoped that new generations of practitioners are not obliged to choose between adopting the deeply engrained institutional prejudices of their profession, or accepting the status of ‘dissident’ or ‘denialist’, unable to publish, teach or even present their views to the industry.


Arya, O. (1973). Changing patterns in the organization of the venereal diseases and treponematoses service in Uganda. Brit. J. vener. Dis, 134-138.
Arya, O., & Bennett, F. (1976). Role of the medical auxiliary in the control of sexually transmitted disease in a developing country. Brit. J. vener. Dis., 116-121.
Burney, P. (1976). Some aspects of sexually transmitted disease in Swaziland. Brit. J. vener. Dis., 412-414.
Gisselquist, D. (2004). Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa. SAHARA J., 114-27.
Hopcraft, M. V. (1973). Genital infections in developing countries: experience in a family planning clinic. Bulletin of the World Health Organization, 581-586.
Kimani J, K. R.-A. (2008). Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence. AIDS, 131-7.
Meheus, A. D. (1974). Prevalence of gonorrhoea in prostitutes in a Central African town. Brit. J. vener. Dis., 50-52.
Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.
Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.


Friday, September 5, 2014

Revised History of HIV in Kenya - Part VI - Family Planning & STIs

Could sexually transmitted infection (STI) programs that started many decades before have been involved in the inadvertent transmission of HIV as early as the 1970s in Kenya? Those targeted by STI programs were women and men who attended STI clinics, or presented with STIs or STI symptoms. A short paper by Peter Piot is often cited to show that HIV prevalence went from 4% in 1981 to 61% in 1985 (Piot P, 1987), and that therefore sex workers (and their clients) must have been incredibly sexually active, and also far more efficient at transmitting the virus to men through heterosexual sex than one might expect (given what has been shown about transmission rates since then). But the possibility that these sex workers and their clients were infected through unsafe healthcare practices in STI and other clinics has never been ruled out.

Jacques Pepin in The Origins of AIDS argues that early STI programs were almost definitely involved in spreading HIV (Pepin, 2011) in the Democratic Republic of Congo. But he uses Piot's paper to argue that sexual behavior took over from unsafe healthcare at some time; why this happened, or when, is not very clear. However, the papers below suggest that the very people among whom HIV prevalence was found to be high would also have been frequent clients in STI clinics. Conditions in health facilities probably improved during the 80s and 90s, which would have accounted for the rate of new HIV infections peaking in the early 90s and subsequently declining. But given that healthcare is not particularly safe in Kenya now, we don't know if HIV is still transmitted through unsafe healthcare, albeit at a far lower rate.

Could invasive family planning methods such as intrauterine devices (IUD), inserted in insanitary health facilities, have been involved in the transmission of HIV, perhaps also as early on as the 1970s? Family planning was most accessible and most availed of in urban areas, and the users were more likely to be better educated, wealthier and formally employed (these are still true of family planning users). Some of the earliest institutions to work with HIV in African countries were those involved in family planning. They were already well established in many countries and persuading people to have smaller families, through any means possible, was what they knew best. That’s not to say they were particularly successful, but they certainly received the lion’s share of funding at one time, until the HIV industry became the top heavy, cash rich bureaucracy that it is today, where any big NGO that toes the party line will get ample funding. Perhaps some of the industry’s obsession with sexual transmission, to the exclusion of most forms of non-sexually transmitted HIV, relates to their origins, which can include puritanical religious beliefs, Malthusianism and neo-eugenicism, to name but a few.

Kenya is said to have been “the first country in Africa south of the Sahara to adopt family planning as a national policy” (Fendall & Gill, 1970), with the earliest family planning efforts starting in Mombasa in 1952. At first, it was decided that Kenya’s population growth was not particularly worrying and the policy started off fairly moderate. There were 25 clinics by 1965 in a country with a population of about 11 million (as of 1969). But in the early and late 60s, censuses showed that population growth was about 3%, far exceeding death rates. An average of 7 children were born to women reaching 50 years of age and average life expectancy was 40-45 years. Those engaged in family planning resolved to reduce fertility by 50%, with intrauterine devices (IUD) being seen as the best contraceptive method for achieving this. Family planning was to be integrated into public health services and it would be free and voluntary (although costs involved in attending the clinic were not covered, which may account for the relative popularity of longer acting methods, which didn’t involve repeat costs).

The number of clinics had reached 160 by 1970, with the biggest being set up in urban areas, along with some of the more heavily populated non-urban areas. Smaller units and mobile teams operated in less accessible areas (although some of the higher populated areas are not urban, such as in the Western and Nyanza provinces, where population is also dense). The Family Planning Association of Kenya claimed to have 17,000 clients in 1965, of which 70% were urban and 30% were rural. It is possible that independence interrupted progress that had been made in the previous two decades. With a growing population and limited revenue, the government needed to provide the free health service they had promised. But the first 20 years or so of family planning may have set some of the patterns that continued for the two or three decades following, and perhaps still exist. Contraception tends to be far more common in urban areas, among better educated, wealthier, urban dwelling people.

British colonial concern about sexually transmitted infections (STI) dates back at least to the 1920s and by the 1970s resistance to antibiotics and penicillin for the treatment of gonorrhea was already common in rural and urban areas. This may suggest that people with STIs had been able to access health services for some time, but that those services were not able to eradicate the most common infections. It is likely that many people did not return for some lengthier forms of treatment, which could involve a lot of discomfort, as well as considerable expense from travel and other costs. A paper from 1971 mentions ‘selected social groups’ being investigated in the past for resistance, including people in capital cities, harbor areas, ‘special elite groups’ (whoever they may be), foreign soldiers and ‘hostesses catering for them’ (Verhagen, 1971). (These are some of the groups among whom HIV was later found to be highest.) But the authors suggest that these groups are not representative of the population as a whole and exclude the majority of gonorrhea patients. It is hinted that the reason these groups are targeted in Kenya is that they may have been the groups most likely to be infected in wealthier countries, such as the UK, but that the analogy didn’t quite work. It is noted that Mombasa and Nairobi have ‘special VD clinics’, although the one in Mombasa only treats sex workers, whereas the one in Nairobi also treats the general population.

A paper published the following year aims to establish the determinants of gonorrhea in Kenya (it is notable that, out of the few papers available in full, many are about gonorrhea, fewer are about other STIs; also, most studies tended to be carried out in a handful of countries, with Kenya being one of the handful). It uses data from monthly checkups for sex workers at the Mombasa and Nairobi clinics mentioned above (Verhagen & Gemert, 1972). One of the authors, Verhagen (and perhaps some of his contemporaries), is interesting for being a lot less judgmental than one might expect, especially given the deep racism later found in institutions working with HIV. Some questions about sexual behavior were deemed ‘too intrusive’ to ask people in their control group. UNAIDS’ criteria for ‘sex work’ is often inclusive enough to be applicable to almost every sexually active person in the country, and even many people who are not sexually active. The authors also draw attention to the fact that attendance for all medical services increased rapidly when treatment became free in 1965.

Gonorrhea tends to infect people who may be more ‘promiscuous’, such as sex workers and their clients. Simple supply and demand would suggest that sex workers must be fairly small in number, whereas clients need to be plentiful. As sex workers are usually female and clients usually male, gonorrhea may therefore be expected to infect more males than females. Verhagen and Gemert find that the male:female ratio is 2:1 in 1964, rising to 6:1 in 1970 and 8:1 the following year. They note that the ratio for syphilis is usually around 2:1. The authors are not able to estimate incidence of gonorrhea but they conclude that Kenya has relatively low incidence, as the disease globally is said to be currently the most common notifiable disease after measles.

Despite earlier findings that patients with STIs are “found among distinct social groups such as the lower social strata, members of migratory or itinerant professions, and other groups characterized by social instability”, this paper concludes that there is “a striking similarity between patients and controls.” Many of the women were single and unemployed (although many were sex workers) and many people who were married and had STIs spent long periods away from their partner, this being more a feature of urban, rather than rural living. Men with STIs usually attributed their infection to someone other than their wife, while women with STIs were often less well educated, as well as being single and not conventionally employed, which strongly suggests that they were very poor. Even among those deemed to be sex workers, it was ‘the smarter and more expensive girls’ who received the monthly checkup, so they may have been less likely to be infected with gonorrhea and other STIs than other clinic patients.

UNAIDS and the HIV industry have a fondness for identifying (and thereby stigmatizing) multitudes of HIV ‘risk groups’, at least one of which almost everyone falls into at some time. In contrast, Verhagen and Gemert assume “that encounters in bars, brothels, dance-halls, and in the street (termed the BBDS category) were the more casual and usually reflected prostitution and promiscuity”. This must have made it a lot easier to target people at risk of being infected with an STI, or of transmitting it to others. The difference in approach may explain the lack of successful HIV prevention interventions, especially before the widespread availability of antiretroviral drugs. Half of the male patients are said to have been infected by someone they met in a brothel, a bar or a dance hall, with brothels only accounting for 10% of all gonococcal infections; the other half met the sexual partner on the street or near where the partner lived. Although the fairly small number of ‘promiscuous’ females infect a larger number of males, fewer of those males go on to infect another partner, such as their wife. The authors neither conclude that all (or most) men are promiscuous, nor that all (or most) females are. The phenomenon of large numbers of single men and married men who live away from their partner, which was very often the case in cities, and a small group of women to cater for their sexual needs, is identified as a major driver of high rates of STI transmission (as it was later said to be in relation to HIV). Even the ‘breakdown in traditional ethics’ said to result from migration and urbanization, frequently remarked on later, had been noted by authors several decades before.

Generally, far fewer women than men were infected with gonorrhea and other STIs. Quite a number of these women were said to be ‘non-promiscuous’, having been infected by a promiscuous partner. Sex workers are often badly educated, unemployed migrants whose marriage may have broken down and who come from a particular tribe associated with these and other factors. Comparing their study participants with a control group, it is found that many of the males are young, badly educated, unemployed, living in overcrowded conditions and are recent arrivals in the study area. The authors warn that “The self-image of an indiscriminately promiscuous community (which in view of our findings in regard to the regularly married is wrong), ostracism against prostitutes and emotional outbursts blaming a particular sex or group of persons are of no help.” That warning, along with others, was to fall on deaf ears. “No distinct high risk groups were found” in the course of this study.

The above papers are of interest to a history of HIV in Kenya because many sexually transmitted infections are a lot less likely to be transmitted through any other route, such as unsafe healthcare. In contrast, HIV is relatively difficult to transmit sexually and easy to transmit through unsafe healthcare, unsafe cosmetic practices and various skin piercing traditional practices. As I have mentioned in earlier posts, HIV is often correlated with higher wealth, better education, employment (as opposed to unemployment) and urban residence, and prevalence is generally higher among women. Many of the factors involved in the transmission of HIV seem to the opposite of those involved in transmission of gonorrhea and some other STIs.

What about factors for STIs and factors for HIV that seem to overlap, such as involvement with sex work, migration, mobility and the like? The above papers, along with others from the decades preceding the discovery of HIV, suggest that sex workers, immigrants, transport workers, migrant workers and those engaged in certain occupations had long been targeted by STI programs. These programs were most prominent in areas that attracted migrants, cities and areas with high labor needs. Could some of these programs have been inadvertently involved in the transmission of HIV to the groups that were later found to have been infected, as if en masse? What about family planning? Could the use of IUDs have infected many women? There is certainly plenty of evidence that conditions in health facilities were poor, that health facilities were oversubscribed, underfunded, understaffed and not the safest place to go for preventative or curative treatment. Even the connections between population growth and density alluded to by some HIV commentators may relate to the relative success of family planning and STI eradication programs in urban, as opposed to rural areas. Higher levels of education and wealth are generally associated with both family planning and health seeking behavior in general; but while these factors are associated with higher HIV prevalence, the opposite is true of STIs.

The massive increase in HIV prevalence among sex workers found in Nairobi, from 4% to 61% between 1981 and 1985, may have been a result of unsafe healthcare, especially in facilities providing STI and family planning services. Historical and contemporary studies show that HIV is only sometimes transmitted sexually; patterns of infection only overlap to a limited extent with those for STIs. The relative contribution of sexual and non-sexual transmission to Kenya's epidemic remains unknown; until it is known, epidemics like that in Kenya will continue indefinitely. Yet the HIV industry is still happy to accuse those infected of being highly promiscuous, and of being indifferent about transmitting the virus to their partners and infants.

[The list of publications below is short and I will comment on other publications in the next part.]


Fendall, N., & Gill, J. (1970). Establishing Family Planning Services in Kenya. Public Health Reports, 131-139.
Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.
Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.
Verhagen, A. (1971). Diminished Antibiotic Sensitivity of Neisseria gonorrhoeae in Urban and Rural Areas in Kenya. Bulletin of the World Health Organization, 707-717.
Verhagen, A., & Gemert, W. (1972). Social and epidemiological determinants of gonorrhoea in an East African country. British Journal of Venereal Diseases, 277-286.


Monday, August 18, 2014

Revised History of HIV in Kenya – Part V - UNAIDS' Rorschach Hypothesis

As I said in earlier posts, HIV arrived in Kenya and remained unnoticed until the 1980s. It is said to have spread rapidly throughout the 80s, especially in certain places (such as Nairobi, Mombasa, Nyanza province and perhaps a few others), but also to have remained low in other places (such as the North and Northeast). The rate of new infections, incidence, peaked in the early to mid 1990s and declined thereafter. So prevalence peaked in the late 90s or early 2000s, with high death rates, which may have peaked in the mid 2000s. The epidemic has a long early years tail (1950s-1980s), a humped back, possibly very humped, and a longish neck. Perhaps the curve resembles an outline of a diplodocus, complete with a little bump where the head should be, but just a small head.
With prevalence peaking at a little over 10%, but only for two or three years, the period of high transmission or incidence would have been six or seven years previously (going backwards again, for a moment). That suggests something catastrophic in the mid to late 1980s and early 1990s that was responsible for much of this rapid transmission. Whatever that something was, it didn't result in rapid spread of HIV before the 1980s, and it ceased in the 1990s. It also ceased to result in rapid spread of HIV after a brief few years. Does that sound like sexual behavior to you? It does to the HIV industry, who have been trying to redescribe similar phenomena in all high HIV prevalence African countries.
So the diplodocus is not the only kind of epidemic curve; there are several dinosaur-like curves that you can spot using UNAIDS data. Many of them look very similar, but there are some whose backs rise two or three times higher than any of those found in East Africa, for example Zimbabwe. A few more countries show an epidemic that exploded in the 1990s but haven't dropped yet, such as Swaziland and Lesotho. The Dinosaur is also a good metaphor for some of the institutions and international NGOs that have systematically resisted one of the best arguments for universal primary healthcare ever (HIV, that is), and continue to resist it to this day. HIV is almost all a matter of individual sexual behavior, they say.
But I did mention being drawn to spatial and temporal factors, rather than 'populations'. Even in my first attempt at characterizing Kenya's epidemic it was clear that there wasn't really a 'national' epidemic. Instead, there were places where HIV prevalence was exceptionally high, and even more places where HIV prevalence was low. Over time, there were places, high and low prevalence, where the curves looked nothing like dinosaurs. They were more like pancakes in low prevalence areas, sometimes with a small piece of fruit under them, and Mexican hats in high prevalence areas. Could this data really describe sexual behavior over time? I was skeptical, not believing that almost all HIV could be sexually transmitted, as the HIV industry was claiming.
Then it was confirmed to me that HIV is frequently transmitted through unsafe healthcare, cosmetic and traditional practices, such as reused syringes and other equipment and practices in all three scenarios, with the second and third involving razors and other sharp objects that are used to pierce the skin, often the same ones over and over again, without any attempt at sterilization. Reasonable people were arguing that various kinds of bloodborne transmission were the only phenomena that could explain the Mexican hats. That accorded well with what I could glean from the literature. It just doesn't accord with what the HIV industry insists: we know it's all about sex, they insist, even when you present instances where it couldn't possibly be.
I can give you about 50 reasons why I don't believe HIV is entirely a matter of sexual behavior without even putting much thought into it (I've already written the list). But here are 10, with supporting links, so you can follow them up if you are interested. I'll supply more in Part VI, perhaps even the rest, I'm not sure yet. Many of the reasons I give overlap with the factors involved in HIV transmission that I listed in Part IV, so if you wondered about any of them, you'll probably be able to match the two lists, eventually. I may even merge them some time, but not now.
1 Prevalence is often higher among rich people. Consult the Demographic and Health Survey (DHS) for most African countries with serious HIV epidemics and you’ll find this. There is a table of HIV prevalence by wealth quintile that I drew up and it is available on a linked blog post I wrote recently.
2 Prevalence is often higher among better educated people. Again, the DHS gives data on this for all high HIV prevalence countries, but here's a graph with some of the data in a table.
Education focus countries
3 High prevalence often clusters around transport infrastructure. Here's a wonderful map of Africa where you can see why there are the several HIV regions I mentioned in an earlier part. But notice that 'spatial accessibility' or 'friction' that they mention do not explain all the regions. West Africa has a less serious epidemic than both East and southern Africa, yet there is good transport infrastructure there.
High prevalence often clusters around big employers, such as mines, plantations, etc. But miners and those employed in large numbers face other threats, such as employer supplied healthcare, public health programs, tests, checkups, STI programs and whatever else. Some may face additional sexual risks when they spend 11 months of the year in an all male hostel, but anyone who thinks that this sub-human treatment only impacts on victims' sexual behavior needs psychiatric assessment.
5 Prevalence is usually higher in urban areas (where non-sexual risks are also higher). But there are multiple differences between urban and rural areas, only some of which relate to sexual behavior. The HIV industry loves going on about 'sexual networks', and not just in African countries. But what about the appalling conditions most urban dwelling people experience when they are born in a city or when they move to one? Slums are dangerous places, where children die of water borne diseases that cost a few cents to cure because what they need is clean water, to ensure they don't get any of a multitude of waterborne diseases. Babies and children die of pneumonia and various respiratory problems, again, easily avoided and treated. But even if you pump a child full of available vaccines and send them back to the same environment, many of them will just die of something else. Adults die of all kinds of things as well, often as a result of the terrible living conditions. Many die or are disabled by road traffic accidents and other kinds of serious injury. Slums, where about 75-80% of Kenya's urban dwellers live, are dangerous. Does anyone who has thought about it really think the only risks they face are sexual?
6 Prevalence is usually lower in rural areas (where non-sexual risks are also lower; have a look at any DHS). This is not to say that people don't face hazards. They also don't receive the benefits of public health programs that are available to people in the cities. Of course, this can protect them from healthcare associated HIV and other diseases but many vaccines work well, a lot of common diseases can be prevented or cured. However, when it comes to HIV, rural dwellers seem to be a lot better off, and inaccessibility of healthcare facilities may have protected them, at least in the recent past. My guess is that while some may be involved in 'sexual networks', just as people all over the world are, these do not explain everything.
7 HIV prevalence is not particularly closely related to ‘unsafe’ sexual behavior. For example, DHS figures for sexual behavior among young people in Zimbabwe show how tenuous the connection is. Even the authors were unable to interpret them. But a careful look at sexual behavior figures for many countries show that the numbers engaging in these behaviors tend to be a lot smaller than the numbers not engaging in them. These levels of 'unsafe' sexual behavior would not be able to explain the Mexican hat graphs in Nyanza and in Kenya's major cities.
Prevalence is often lower among those who never use condoms. As the linked article shows, condom use is often associated with higher rates of transmission than non use. The authors try to imagine arguments to show why condoms look like they are failing more often than not, but they don't come up with anything convincing. The figures in the article have been superseded and there's a more up to date table in a blog a wrote a short time ago. My guess is that condom use is higher among urban dwelling, better educated, wealthier, employed people, and that's why you get these same patterns for condom use in so many countries. Again, this strongly suggests that HIV is not purely a matter of sexual behavior.
9 HIV prevalence is low in areas where ‘intergenerational’ marriage and sex, that is, between people of very different ages, are more common. I'm linking to a blog post I wrote recently, no point in repeating the whole thing again. The data is from DHS for various countries.
10 HIV prevalence is low in areas where ‘traditional’ practices are more common, such as traditional medicine. These tend to be more common in rural and isolated areas. A possible exception to this is genital mutilation. There are two kinds, only one of which is 'traditional'. The first kind takes place in a health facility, so that's usually male genital mutilation. The second kind does not take place in a health facility and includes male and female genital mutilation. It's hard to say which is more likely to transmit HIV. If mass male circumcision was being carried out in a health facility where infection control procedures were not followed properly, not an uncommon occurrence, then healthcare associated transmission could be very likely, and would be serious; some practitioners are carrying out twenty operations a day, apparently. Traditional circumcision, which has its own hazards, is carried out in entirely unsterile conditions and adverse events are common. But it may be less likely that a HIV positive person is being circumcised along with other initiates. Prevalence should be low among young uncircumcised males. Even if they engage in sex before the wound has healed, those with whom they have sex should also be less likely to be infected. But whether done in a clinic or in a field, genital mutilation is risky. Female genital mutilation generally takes place in unsterile conditions and the risks of some forms may be higher than those faced by males. But female genital mutilation is also more likely to take place in rural areas, where HIV prevalence is lower. It is said that almost 100% of Ethnic Somalis in Kenya's Northeastern province, both male and female, are genitally mutilated, but HIV prevalence is very low.
HIV probably did very little for years in Kenya. But next to nothing for years is the way to go from being a species jump that should never have survived to being a pandemic. Perhaps a clearer history of how it survived and spread, to explode in the late 80s or early 90s, will tell us more about what is still driving transmission, in Kenya and elsewhere. But there are already many reasons for believing that HIV is not only transmitted through sex. One would want to be seriously disturbed to interpret every factor involved as evidence of sexual behavior.


Friday, August 15, 2014

Revised History of HIV in Kenya – Part IV - Diversity

Why is HIV spread so unevenly? In some parts of Kenya prevalence is at 'hyperendemic' levels, over 20%, almost 30% in one county. Yet in other counties it is low, 1% or lower. If, as we are constantly told, 80%, even 90% of HIV transmission is a result of unsafe sex (most of the remaining 10-20% being a result of mother to child transmission), what amazing sex lives people in some counties must have (or disgraceful, if you prefer). And what dull (or worthy) lives those in other counties must have, apparently only having sex for the purpose of procreation.
If, on the other hand, HIV is not always a result of sexual behavior, if many people may be infected through unsafe healthcare, even unsafe cosmetic and certain traditional practices, some of the factors involved in HIV transmission rates, low or high, start to make a lot more sense. The list of factors is long (over 40), but the italicized paragraphs are the kind of explanations given by the 'it's all about sex' camp, so they are mostly the same. Yes, some HIV transmission is a result of sexual behavior, nobody is denying that, but some is not. Also, some areas where HIV transmission is high are in need of further study; a priori explanations for high and low prevalence have no place in science (though they seem to receive a warm welcome in a lot of papers on HIV epidemiology).
Prevalence is often higher among Christians than Muslims, and generally among males than females; not sure why this is so; the majority of HIV positive people in the world live in predominantly Christian countries, meaning that a lot more Christians than non-Christians are infected; why this is so is not clear, although both healthcare access and HIV prevalence are noticeably low in some Muslim dominated countries
Men less likely to be circumcised; also Christians are 'less restrained' in their sexual behavior than Muslims
There is no clear evidence that circumcision reduces HIV transmission and it could only influence sexual transmission, at best; however circumcision is risky if carried out in unsafe healthcare facilities or in traditional settings
Circumcision 'cleaner' or 'more hygienic', although this is a hypothesis, there is no unambiguous evidence
The vast majority of HIV positive people live in countries that were colonized by the British. This may relate to healthcare facilities, access to healthcare, health seeking behavior, infrastructure, stability, etc
It's somehow related to sex
Condom use
HIV prevalence is higher, often far higher, among people who sometimes use condoms than among those who never do, suggesting that HIV risk is not always sexual
Those who are already infected are more likely to use condoms
Cultural practices such as female genital mutilation (FGM) may increase the risk of being infected, although it increases both sexual and non-sexual risks; yet prevalence among people who practice FGM is generally low, which suggests that there are other factors involved
Increases HIV transmission; if prevalence is low this can be explained away by reference to attitudes towards extra-marital sex, etc
Depo Provera
Increased risk for women taking it and for their partners
Denies that this is a risk and claims that the benefits (prevent conception) outweigh any disbenefits, which don't exist anyway
Educated people may have better access to healthcare and be more likely to use healthcare
Educated people have access to bigger sexual networks
Employment status
People with a job can afford healthcare, although this may not be safe healthcare; jobs may include healthcare or health insurance; some occupations provide healthcare services;
People with a job have more money and therefore access to bigger sexual networks; despite prevalence generally being higher among employed people, some suggest that unemployed people have little else to do but have sex
Prevalence is usually higher among women, possibly because they have more need to use healthcare services, especially when pregnant and giving birth; they are also more susceptible to sexual transmission
Women are more vulnerable and have less power to make choices; they are usually victims, otherwise they fall under one of the many categories of sex worker
Higher fertility may increase healthcare exposure, although it is often associated with low prevalence areas, rural areas, etc
Higher fertility means more unprotected sex
Healthcare may not always be safe, which may explain why countries with good access to healthcare for everyone, such as Botswana, may result in higher HIV prevalence
Sick people, including people with HIV, seek healthcare, which is why healthcare may seem to be associated with higher HIV prevalence; this is especially true of STIs
HBV and HCV are much more likely to be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices, also injection drug use
Presence of HBV and/or HCV are signs that the person is either promiscuous or an intravenous drug user (or both)
Rates can be extremely high in some populations because it is very easy to transmit, sexually and through other routes; it plays a role in being infected with and transmitting HIV but the role is complex
It is a sign that people infected engage in unsafe sex and increases risk of transmitting and being infected with HIV
It is neither clear that inequality is associated with higher risk, nor why this may be so
People are more vulnerable to sexual risk, especially women
Good infrastructure is often associated with high HIV prevalence, which may suggest better access to unsafe healthcare
Good infrastructure gives access to bigger sexual networks
Prevalence is usually lower among men than women, which leaves a question mark over instances of higher prevalence among men when they are found, for example, Muslim men in Kenya; prevalence may be lower because of lower use of health facilities
Men are considered to be mere spreaders of sexually transmitted disease, whether they are rich or poor, urban or rural dwelling, etc
Sometimes HIV prevalence is far higher among married than unmarried people and it is not clear why
Married people are less likely to use condoms; they also have extra marital sex, usually the men, then they go home and infect their spouse
Migration can be for work, which may involve work-related healthcare, which may be unsafe and may not be subject to levels of scrutiny faced by public facilities, however scrutinized  they may be
Migrants, being away from home, either have other sexual partners or visit sex workers; they then return home to infect their spouse
Possibly increases access to health facilities, but mobility on it's own doesn't seem to explain high prevalence
Mobile people have access to bigger sexual networks
Figures vary, with prevalence higher among Muslims than Christians in some countries (eg, Burundi, Rwanda, Mozambique, but not Kenya or Tanzania), also higher among Muslim men than women in others, eg Kenya; not sure why this is so
Men more likely to be circumcised; also Muslims are 'more restrained' in their sexual behavior than Christians
National borders
High HIV prevalence has been reported at border areas in the past and rates of unsafe sexual behavior may be higher; but the sex workers and long distance drivers who are said to be responsible for high rates have often taken part in STI eradication programs and may frequently use STI clinics
Long distance drivers have sex with sex workers, then they go home and have sex with their spouses
Occupation - armed forces
Members are unlikely to have any option as to whether they take part in various health programs, tests, etc; healthcare is likely to be free, which means usage is also probably higher
They have access to bigger sexual networks and frequently visit sex workers
Occupation - fishing
Prevalence is high in fishing communities, not necessarily highest among the fishermen; also, very high prevalence seems to be a feature of only some fishing communities, especially lakes; not sure why HIV prevalence is so high
Fishermen do risky work, therefore they are not bothered by sexual risk; also, they spend a lot of time away from home; also, they use sex as a bargaining tool
Occupation - mining
Artisanal mining is not so much associated with HIV so this probably applies to industrial scale mining; the work-related healthcare to which miners have access (they may even be compelled to receive certain health services and tests) may not be safe
Miners work a long way from home and don't see their family much so they have extra-marital relationships and/or visit sex workers, then go home and infect their spouses
Occupation - teaching
Prevalence has been claimed to be higher and lower among teachers, at different times and places; they probably face similar risks to other public sector employees, whatever those may be
Teachers frequently have sex with their pupils (which may be true, and should be addressed, but it may turn out to have little to do with HIV transmission)
Occupation - transport
Transport workers may use health facilities more; also, they may have been persuaded to take part in STI eradication programs as they have been blamed for all sorts of things; these STI programs may not always have been safe
Transport workers are mobile, which means they have access to bigger sexual networks; then they go home and infect their spouses
Sometimes associated with higher transmission, sometimes with lower transmission, therefore not clear. It is not only practiced by Muslims but also by some tribes and even at least one Christian sect in Kenya
When prevalence is higher, this is because polygamy involves 'concurrency'; when lower, it's because men with more than one wife don't need to have extra-marital sex, or not as much
Population density
Increases pressure on health facilities
Said to increase the size of sexual networks
Population growth
Increases pressure on health facilities
Said to increase the size of sexual networks
HIV prevalence is often lower among poorer people, suggesting that they may face lower risk from, for example, unsafe healthcare because of reduced access; however, being poorer means that the only healthcare available may be unsafe
If prevalence is high, poorer women are more vulnerable (to sexual transmission) for various reasons;  if it's lower, poorer people are less likely to be part of a 'sexual network’ or their networks are likely to be smaller
There may be some kind of drug use that involves cutting or skin piercing (seems unlikely injection drug use would be common); healthcare is unlikely to be very comprehensive or safe; tattooing and traditional medicine may be additional risks, perhaps also scarification, blood oaths, etc
They have sex with other prisoners, the implication being that the sex includes anal sex; and/or injected drugs or drugs that involve skin piercing; condoms are usually not permitted
Rural dwelling people have less access to health facilities and infrastructure, which may go some way to explaining why prevalence is usually lower in rural areas
Rural dwelling people have access to smaller sexual networks
This has been shown to increase susceptibility to infection and onward infection, which suggests that some people have sex, not very surprising; but endemic schistosomiasis, which is very cheap to treat, suggests weak healthcare systems
Lots of people having lots of sex with lots of other people all the time: schistosomiasis only adds to what is a 'known issue'
Sex work
Prevalence among sex workers is low among some sex workers in Western countries unless they also engage in injection drug use but their biggest risk in countries with unsafe healthcare could be their frequent exposure to STI clinics and STI eradication programs; also, a lot of what is referred to as 'sex work' is in fact sex between people who are in a relationship or married; many people who are related, in a relationship or married also do business with their partner or relative; 'gift giving' is sometimes said to be a form of 'transaction' between two people who have sex; this is a very stigmatizing use of the term 'sex work' (a bit like the term 'orphan', which refers to children in developed countries who have lost both parents, but children who have lost one parent in developing countries; or the word 'trafficking' which seems to refer to just about anything that involves sex and that can attract funding to 'rescue victims' from)
Sex workers are forced into sex work by poverty, powerlessness, vulnerability, etc, but their consequent risks are high and entirely sexual, unless they are also injection drug users
STIs do not only suggest unsafe sexual behavior, they also suggest a health system that is failing; some are also transmitted through non-sexual routes, such as herpes and HIV
STIs are a sign that a person engages in unsafe sex
TB is likely to be an occupational disease in deep mines, though mining operations deny this, as they don't want to compensate those who contract it, pay for their treatment or improve conditions in mines; it increases HIV transmission in both directions
HIV positive people are more susceptible to TB
Prevalence is high in some tribes and low in others (high among Luos, low among Somalis in Kenya, for example), which suggests that there may be several factors involved; there are 'risky' practices in tribal groups among whom HIV prevalence is low, as well as high (for example, female genital mutilation, which is widespread among Somalis)
'Tribal' practices and/or 'traditional' practices can be wheeled out on any occasion, either to explain high prevalence or low prevalence; they often involve sex or some form of brutality an are generally inflicted by men on women
Urban dwelling people have easier access to health facilities and other infrastructure
Urban dwelling people have access to bigger sexual networks
War/civil conflict/refugee camps
Prevalence is generally low during wars and only increases after the war has finished, perhaps because health seeking behavior changes during wars, health facilities become less accessible, money is short, infrastructure is destroyed, etc
If HIV is transmitted it is because people take advantage of the situation, rape and other forms of sexual violence being common; but as prevalence is usually lower it is claimed that sexual networks become smaller, people return to rural areas, etc
Prevalence is often higher among wealthier people, suggesting that they may use healthcare more frequently; they may also face occupation related risks that are also non-sexual
Wealthy people can become part of larger sexual networks; they have more opportunities for sex and are more likely to avail of these opportunities
Prevalence among widows and widowers can be very high but it is not clear why
Widows are, in some cultures, inherited, having been widowed because their husband (obviously) died of AIDS; they are 'cleansed' (have sex with their inheritor) who may be the brother of the deceased, and infect him; he goes on to infect his other partners, including his spouse
The list above makes no claim to be exhaustive. When there is so much diversity in HIV epidemics within and between countries, why would anyone conclude that almost every factor is, ultimately, a matter of sexual behavior, or somehow relates to sexual transmission? It's no wonder, given the above list, that HIV positive people are feared, even despised. It is the view that transmission is almost always sexual that results in the stigma UNAIDS and other institutions claim to abhor and pretend to be fighting; they are the source of the stigma. HIV 'prevention' programs that include some or all of the italicized arguments above merely spread the stigma.