Friday, April 9, 2010

Malawi Needs Good HIV Research, Not Bad HIV Laws

Malawi has this cunning plan to 'outlaw HIV transmission' by making it a crime to 'knowingly' transmit HIV. A spokesperson for the ministry involved said "The underlying factor is that if anybody knowingly infects somebody...that means he commits an offence." I haven't been able to find a copy of the bill but apparently it means that if a HIV positive sex worker fails to let partners or clients know their status, they will be liable to prosecution.

I wonder if their partners or clients will also be liable to prosecution for failing to reveal their status. After all, people availing of the services provided by sex workers should be equally aware of the danger of transmitting and of being infected with HIV, along with various other sexually transmitted infections (STI). The spokesperson was unable to say what would happen if both parties were HIV positive and referred to the bill as a challenge. He also said what they are doing is educating the populace. I assume he was trying to make a joke, however inappropriate.

I would also like to know where the law would stand with regard to non-sexual transmission of HIV. For example, where health services use shared needles, syringes or medicine vials or engage in other potentially hazardous practices, would they be liable to prosecution? Supposing they failed to take precautions specified under normal occupational procedures, how would the law stand? Could a HIV positive mother be accused of criminally infecting her child, either in the womb, during birth or through breastfeeding? Would a HIV positive intravenous drug user (IDU) be liable by sharing injecting equipment?

If you accept the received view of HIV transmission and believe that 75% of it is transmitted through heterosexual sex and only a very minor proportion through unsafe medical procedures, you may not worry about medical transmission (though this doesn't answer the questions about IDUs or transmission by mothers to their children). But if doubt were cast on that received view, if medical transmission were more common than previously supposed (admitted?), or if it were even more common than heterosexual transmission, you might consider the question more important, especially if you were a health professional.

The trouble with medical transmission of HIV is that it has received very little research. Figures you hear bandied about are mostly based on assumptions which should never have been allowed to stand untested, as they have been, for several decades. But among the few bodies of data that have been collected, medical transmission has been found to be a risk in almost all of them. This doesn't mean that medical transmission has been demonstrated, just that those receiving injections have a higher risk of subsequently being found to be HIV positive. Notable also is the fact that some of this research goes back to the mid 1980s.

Data from Malawi is the most shocking. 54% of HIV infections are found among those who have received injections in clinical settings. Other countries report lower percentages but the average is 21% and the mean is 19%. For me, the worst aspect of this is that none of these pieces of research are national in scale and only a handful of countries are involved (DRC, Uganda, Rwanda, Tanzania, Zimbabwe and Malawi).

The Malawian spokesperson is right in saying that there no straightforward answers to questions that arise about this proposed bill, but not for the reasons he thinks. If medical transmission of HIV is higher than has been previously assumed, it would be more worthwhile, indeed, more straightforward, to investigate this and provide some remedies. That would certainly be more feasible than trying to create laws of dubious ethical standing to reduce HIV transmission.

On the whole, it would be a good thing if HIV was less likely to be transmitted sexually because it is difficult to influence the sexual behaviour of whole populations and efforts so far have failed. In contrast, it should be much easier to influence the practices of existing health personnel, increase the number of trained personnel, increase the resources available to them and increase access to health services. And improving health services will have benefits that far exceed those to HIV alone. As to how providers of medical services can regain the trust they will have lost, that will be no easy matter. But I don't think anyone would opt for continuing to transmit HIV through medical procedures, if this is actually happening.

The admission that medical transmission of HIV could be higher than previously thought, and even that sexual transmission could be lower, may be a hard one to make. Of course, it may not even be true that medical transmission is higher and sexual transmission is lower. But now that the possibility has been raised, we can not continue to fail to research this vital area of HIV knowledge. Let us stop lying about what we don't yet know.


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