Thursday, May 20, 2010

We in the UN Have Been Lying About HIV and Now...

Myself and a friend are taking a trip around Lake Victoria to visit some of the places where HIV prevalence is exceptionally high. Countries around the lake, Kenya, Tanzania and Uganda, all have similar HIV prevalence of between 6 and 8%. But in many places on or close to the lake shores, prevalence is (or was) often well over 20%. Bukoba in Tanzania, Suba and Homa Bay in Kenya are examples, as is Rakai in Uganda.

Our first stop was in Shirati, Tanzania, where there is a Mennonite run hospital. We were made very welcome there and visited several people who have worked for a long time with HIV and health in general. Most people were happy to talk about their experiences and concerns and we were introduced to people who work in various positions in areas around Shirati.

However, even people who work closely with HIV, as well as lay people, seem to regard HIV as being mainly sexually transmitted. This is not surprising because most public education campaigns and most money are concentrated on sexual transmission. People have been listening, to a greater or lesser extent, to all sorts of advice about using condoms, having fewer partners, testing for HIV and other sexually transmitted infections and various other measures thought to reduce transmission of HIV.

But these HIV prevention interventions have had very limited success, despite exaggerated claims by some of the people behind the emphasis on sexual transmission. Perhaps, as a lot of data shows, people in these three countries already take precautions to avoid HIV, but without success. Research has shown that sexual behaviour in African countries differs greatly from place to place, just as it does in non-African countries. In fact, there is no evidence that sexual behaviour thought to be unsafe is that much higher in African countries where HIV prevalence is high. On the contrary, often, areas that have high HIV prevalence also have low levels of unsafe sexual behaviour.

So, if levels of sexual behaviour do not explain differences in prevalence within and between various African countries and non-African countries, it is possible that HIV is also being transmitted in various non-sexual ways. Two prominent examples of this are transmission through unsafe medical procedures and through cosmetic procedures. In the former group, there could be reuse of disposable equipment or failure to sterilize equipment. In the latter, again, use of equipment that is not properly sterilized.

People we talked to showed high levels of awareness of possible exposure to HIV through sexual behaviour and this is corroborated by various research that has taken place over many years. For a long time, people have been able to list all sorts of things about sexual transmission of HIV but this has had little or no effect on HIV prevalence rates in those countries. But few mention non-sexual transmission and even when they do, they don't appear to know of ways to avoid non-sexual transmission.

Some of the people we talked to confirmed that they and their children had their hair cut by a machine that breaks the skin, especially where there are sores or new scars. But they were unaware that it is necessary to sterilize the equipment properly to avoid transmitting infection to the next person who uses the same equipment. They said that hairdressers sterilize equipment using methylated spirits or water. But they didn't know that this is not enough to ensure that all possible infection has been eliminated. They also thought that HIV infection only lives on instruments for a very short period, which is a common belief, though wrong. [There are abstracts to a couple of articles on this subject on, here and here.]

There is remarkably little interest in non-sexual transmission of HIV among the mainstream, UNAIDS, WHO, CDC, UN and others. There seems to be a reluctance to take on board the considerable amounts of research that suggests that a significant amount of HIV transmission occurs through non-sexual means, whether in cosmetic or medical contexts. This is surprising because non-sexual transmission has been recognised by these bodies since the mid 1980s, when HIV had only recently been identified as the virus that causes Aids.

For example, regarding medical conditions in developing countries, the UN has this advice for its employees:

"Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."

This suggests that the UN is perfectly well aware that unsafe medical practices are widespread enough to be a threat to their employees. But they and other institutions don't seem to extend the same advice to people who live in those countries and would be likely to visit available facilities more frequently. Maybe the UN is even in conflict with UNAIDS in some instances because the latter claim that medical transmission of HIV in Kenya is around 0.6% of all transmission, meaning that they think health facilities in Kenya are very safe.

The UN goes on to say:

"In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care."

Am I being oversensitive here in detecting a total disregard for the health and safety of people who happen to live in 'several regions', while paying a lot of attention to people who generally don't have to avail of the services that the general populace have to put up with? Perhaps the UN would like to reveal what this 'notable share of new infections' is and inform UNAIDS, WHO, CDC and others. In particular, perhaps they would like to inform people who live in any of the countries they are worried about. After all, 'we' are not all privileged with being UN employees.

The UN certainly knows how to avoid medical transmission when it comes to its own employees:

"None of us should ever share with another person a needle, syringe or equipment used for injection. If we receive medical care from the UN system medical services or from a UN-affiliated health-care provider, we can be confident that every effort has been made to ensure that injecting devices used to administer a shot are sterile and will not expose us to HIV. If we need to give ourselves a shot outside a UN health-care setting, we should only use disposable needles and syringes and we should use them only once. Because safe injection practices are not followed in all healthcare settings and it may not always be possible to purchase sterile injection devices, the WHO medical kit that is made available to all UN agencies includes disposable syringes and needles."

This means that we have all the information and know-how necessary to reduce non-sexual HIV transmission. Now that we know all this, it's time we went out to tell all the people the truth. We have been telling them lies for a long time now. We have spent years telling people that HIV transmission in Africa is mainly sexual and arguing that this is because Africans have so much more unsafe sex than non-Africans. We can no longer shore up this argument, nor should we. We have the means to cut HIV transmission significantly straight away, we don't need to wait for expensive vaccines or other programmes that will take years to be effective, if they ever are effective. We just need to admit that we have been lying and make amends before more people become infected and die.



Claire said...

is there a medical hypothesis for the increased prevalence around Lake Victoria? the sexual hypothesis would say that there was large income disparity and therefore prostitution or benefits provided for sex, with fishermen as those paying.

Simon said...

Well, this article is about the disparity between what UN tells its employees and what UNAIDS tells the world about HIV transmission in some high prevalence African countries.

In other words, the received view is that medical transmission is almost non-existent in Kenya, Swaziland and other countries, yet they tell their employees to avoid medical treatment that could give rise to blood risk.

It may turn out that research into medical facilities is required here, it's hard to say as we are not doing a formal survey.

The sexual hypothesis may well be correct about the large income disparity and prostitution, although it is women who pay the most, not fishermen, also quite a lot of children.

But this is not incompatible with some medical and cosmetic transmission and it seems odd for institutions to dismiss their contribution, especially when they recognise the risk to their own employees. That, at least, should give some rise to some sort of investigation.

As for income disparities, there are disparities in many places but prevalence around the lake is higher than anywhere else in East Africa. And there is prostitution aplenty in other places but not such high prevalence of HIV.

claire said...

Thanks Simon. UN advice is indeed hypocritical.