Sunday, September 26, 2010

The Limits of Human Promiscuity

In response to a raft of articles challenging the view that heterosexual transmission is by far the major mode of spread of HIV, 15 academics penned a paper that concluded that “there is no compelling evidence that unsafe injections are a predominant mode of HIV-1 transmission in sub-Saharan Africa”. One of their ‘main arguments’ is that “Unsafe injections are not sufficiently common to play a dominant part in HIV-1 transmission in Africa”.

But how common do unsafe injections need to be? Even the WHO accepts that up to 40%, and in some areas, as much as 70% of medical injections are unsafe (also that as much as 70% could be unnecessary). They accept that 30% of hepatitis C (HCV) and 40% of hepatitis B (HBV) is transmitted through unsafe injections.

Another of their arguments against medical transmission of HIV is that “Transmission efficiency of HIV-1 for injections in African health-care settings is overestimated and is far less than 2·3%”. Ok, but what is the figure and how does that refute the significance of the WHO’s findings? And what about other procedures, aside from injections? UNAIDS has acknowledged that little is known about unsafe injections, yet they seem very confident in dismissing their contribution to HIV epidemics in African countries.

This group of academics suggest that “Analyses to assess the association between a history of injections and HIV-1 infection do not adequately take into account reverse causality and confounding”. And what analyses have they and their colleagues in the HIV industry carried out? There is such a thorough lack of papers on nosocomial and/or iatrogenic HIV transmission, anyone would think that the industry was afraid of what such research may reveal. If analyses to date have been lacking, they don’t seem in a hurry to fill the gap in our knowledge.

The authors seem to be suggesting that those who receive a lot of injections may already be infected with HIV and, therefore, suffer from a lot of illness. But this simply underlines the need for further investigation. They claim that people who get a lot of injections may be receiving treatment for sexually transmitted infections (STI), so they are already at risk of being infected with HIV. But there is still a danger that people receiving injections for any reason, including STIs, are at risk of being nosocomially infected with something they don’t already have.

Many people receiving injections for STIs do so in clinics that specialize in STIs and have a lot of clients who have multiple risks for STIs and other blood borne viruses. This doesn’t mean they must all have been infected sexually. Rather, it could point to clinics being even more hazardous than previously recognized. They have a tendency to concentrate those most likely to be infected with HIV in the one place and thereby increase their risk.

Their argument that “Apart from mother-to-child transmission, HIV-1 infection is rare in children” is swiftly dealt with in a paper by Savanna Reid, who points out that childhood prevalence does not increase with age because many HIV positive children die. Indeed, the number of cases of infants and children who are HIV positive and their mothers are HIV negative has long been a cause for concern. Yet it has gone uninvestigated by the industry.

They have a few other ‘main arguments’ but almost everything they claim seems to follow from the ‘behavioral paradigm’, the belief that almost all HIV transmission in African countries is through heterosexual sex. Every piece of evidence that appears to challenge the paradigm is dismissed as being impossible by reference to the paradigm itself.

One must ask, what level of HIV transmission from unsafe injections would be acceptable? When the mere possibility of nosocomial infection occurs in Western hospitals, such as in the UK, the US or Australia, tens of thousands of people are recalled and tested for blood borne infections of various kinds. This never happens in African hospitals, despite there being ample evidence that such infections occur. Even UNAIDS' 'estimate' of 0.6% transmission still represents thousands of preventable infections.

Although I think the (predominantly) heterosexual transmission theory of HIV in Africa is grossly under-supported by evidence, this is not the only objection. There seems to be a complete lack of fellow feeling among those who cling to the theory, a lack of humanity. I believe that some people all over the world have a lot of sex, but most don’t. And I don’t believe anyone, let alone the majority of people in a handful of countries, can possibly indulge in levels of sexual activity that would explain HIV prevalence levels found in these countries. But such perverse views as the behavioural paradigm are the orthodoxy.



Anonymous said...

i agree that behavioral is overshadows blood perhaps dangerously so-- i would be interested to see some stats on role of wagangas and such..

Simon said...

Thank you for your comment. If I find something on traditional medicine I'll post it up but I am dealing with 'modern' health facilities, run by the government, NGOs, private institutions, etc. There is a lot of evidence that standards are not high in a lot of facilities in Kenya.

But there is also evidence that a lot of people have little or no access to them. People are far more likely to resort to Waganga in isolated areas, away from health facilities. And surprisingly (or not), HIV prevalence is not very high in isolated areas.

Unfortunately, rates are increasing now, but that may because of encroachment by non-traditional health services.

Much of North Eastern Province and the Northern parts of Eastern Province, along with some other isolated areas, have very low prevalence figures. This pattern is also found in other countries.

I have heard stories about Waganga and, if HIV prevalence was high in the areas where they operate, there would be a high risk of transmission. But perhaps they operate mostly in low prevalence areas.

There may be no causal link between non-traditional health services and high HIV prevalence, just a correlation. But I think the matter is in serious need of investigation.