Don't Have Sex and Don't Go to the Hospital

Over the past twenty years or so, there have been a few papers pointing out that HIV transmission through unsafe medical practices, especially in Sub Saharan African countries, may be higher than previously thought. These papers don't seem to have had much impact and when modes of HIV transmission surveys have analyzed the part that such practices might have played in the current HIV pandemic, they have usually reported that heterosexual transmission is the most common, followed by things like male to male sex, intravenous drug use, commercial sex work, etc.

The possibility of unsafe medical practices playing a large part in HIV transmission is being raised again, though it is hotly disputed by some. But given the amount of guesswork involved in estimating HIV prevalence in high prevalence countries, it would not be surprising if the figures were open to question. If it were established that HIV was regularly transmitted through medical practices, it would certainly dent the widely held belief that HIV can be fought purely by trying to control people's sexual behaviour.

I and some others have long opposed the view that sexual behaviour alone can adequately explain the massive rates of HIV transmission in certain countries, compared to the relatively small rates in other countries. This is not to deny that sexual behaviour is an important factor in HIV transmission, just to question the idea that certain people in certain African countries have more sex or have more partners or whatever, than people in other countries around the world.

But unsafe medical practices would be unsurprising in a country that spends so little on health, a country that has so few properly trained medical personnel, so few hospitals, a country where the vast majority of people can't afford to go to a health professional when they are ill and who may often be better advised not to go at all.

The cries of those who claim that massive funding for HIV treatment and care is justified may be well founded, I don't know. But one thing is for sure: in the time that HIV treatment has been well funded, hospitals and clinics have not improved noticeably, rather, they have disimproved. Staff numbers have fallen. Disease rates have risen. All the indicators suggest that the disimprovements in health that started in the 1980s, before Aids had had much impact, have continued right up to the present, high Aids funding levels notwithstanding.

So, as the anti circumcision lobby might say, this is not a good time to start mass male circumcision programmes. There may never be a good time, the case for mass male circumcision is still unconvincing, but no one in their right mind would opt for an operation on their penis or the penis of their child or relative until health services have been improved. People need to be confident that they will get better in hospital, not worse. Children in Swaziland whose mothers are HIV negative and who had attended hospitals and clinics a lot were found to be most likely to be HIV positive. Similar studies have been carried out in other African countries.

Whether you are going to a clinic or hospital for HIV related services or anything else, you are in danger of suffering from unsafe medical practices. The health service in Kenya is on its knees. Expensive HIV treatment or circumcision programmes either need to have their own infrastructure built from the ground up, which seems highly inefficient, or they have to wait until health services are built up in their entirety.

Kenyan's are still waiting for their health service to be rebuilt. The circumcision programmes have stalled, thankfully, some would say. And the HIV treatment campaigns are seriously hampered by the condition of the country's health services. Indeed, antiretroviral treatment is probably also hampered by the low levels of health in the population, but who is going to notice that? There just aren't enough health professionals to bear witness to the chaos that exists.

The whole issue is a reminder of how little is known about the true nature of different HIV epidemics in different countries. Many of the figures that are used to shape the various approaches to the disease are pure guesswork and interpretations are often strongly shaped by influences that have little to do with science or even reason, for example politics, religions and 'morality'.

A sensible conclusion to draw from warnings about the safety of medical procedures would be to spend more money on health infrastructure and especially on training more health personnel. More money is probably need for HIV specifically, but it will be money thrown down the drain until health infrastructure has been improved.