Tuesday, April 26, 2011

Blinded by Influence: the 'Rightness' of Big Funding

Matthew Black has raised some issues in response to my last post, which I would like to answer in detail. It appears that his opinion is based to some extent on a very brief article which denies, but doesn't adequately refute, some of the most pressing arguments against the behavioral paradigm, the view that HIV is almost always transmitted sexually in African countries.

Firstly, in saying that I don't believe all HIV is transmitted sexually, I am not claiming that it is never transmitted sexually. Nor am I saying that it is mostly transmitted non-sexually, by unsafe health care or any other non-sexual modes.

What I am saying is that we do not know the extent of non-sexual transmission and that it is vital to address this lack of knowledge in order to judge how much time, effort and resources are spent on each mode of transmission.

Aside from lack of thorough research into non-sexual transmission, particularly through unsafe injections, but by no means limited to that, no adequate explanation has ever been given as to why heterosexual transmision of HIV is realatively uncommon outside of a few high prevalence countries, mostly in sub-Saharan Africa.

People all over the world have sex, some of them have a lot of sex and it is often 'unsafe'. But rates of sexual transmission appear to be hundreds of times higher in a few African countries, if UNAIDS and the AIDS orthodoxy are to be believed.

Another anomaly is what is known about non-sexual HIV transmission: not only is it far more efficient than heterosexual transmission (regardless of which sets of figures you actually use) but it is also the commonest form of transmission in most Western countries and other countries where prevalence is not excessively high.

Indeed, aside from men who have sex with men, the only high prevalence group in Western countries is intravenous drug users. Even sex workers who are not intravenous drug users are very unlikely to be infected with HIV.

The Service Provision Assessment data I refer to in my previous posting is the latest available from Measure DHS and this kind of survey only takes place about every five years, the same as most demographic and health data relating to HIV (an assessment was carried out last year but the data is not yet publicly available).

But health services are not receiving anything like the sort of resources that are being thrown at antiretroviral drugs. If anything, as populations increase, services are less and less able to cope with demand.

But we don't need to ask if health facilities in high HIV prevalence countries are risky places for those who wish to avoid HIV, hepatitis and other blood borne viruses. The UN itself bears witnes to the fact that they are not trustworthy. The UN warns its own personnel to avoid health facilities that are not approved by the UN itself because of the known risks.

But when it comes to advising African countries about HIV risks, the UN changes its story and says that HIV is unlikely to be transmitted non-sexually, particularly through unsafe injections. Why there is this discrepancy in their advice, we are not told.

But despite the WHO claims in the brief Continuing Medical Education Journal document mentioned above, the WHO has also published material which accepts that 70% of injections globally are unsafe and an unknown percentage, perhaps as high as 15 or 20%, may be contaminated with HIV. Huge percentages of hepatitis B and C are transmitted by unsafe injections. And the WHO is part of the UN.

Mr Black may be interested to know what happens in Western countries when there has been a suspected case of unsterile equipment being used on patients in health facilities. Hundreds, thousands, even tens of thousands of people are contacted and advised to be tested for HIV and other viruses. I cite just one example here, but new ones are reported every month. But I have cited others in the past.

On many occasions in rich countries, nosocomial transmissions have been identified and treated, where possible. Such investigations do not take place in countries that have very poor health facilities, and that's what I and Gisselquist, Brody, Potterat and a number of other people are questioning.

People in Western countries do not tolerate such outbreaks occurring. When they do occur an investigation follows. As a result of the investigation, procedures are improved accordingly. Why are the authors of this CMEJ article prepared to tolerate conditions in African countries, where health facilities are so lacking in every way, that would be unthinkable in Western countries?

And more importantly, how can UNAIDS and others deny that non-sexual HIV transmission is worth investigating in countries where they have not even bothered to investigate it?

The issue, Mr Black, is not just about whether sexual transmission is or isn't responsible for most HIV infections in a handful of high prevalence countries: the issue is that the contribution of non-sexual transmission, especially through unsafe healthcare, has never been properly evaluated in those countries. And just as UNAIDS seem afraid to use African health facilities themselves, they also seem afraid to investigate them.



Matthew Black said...


Thanks for your picking up on my comment. It's always good to see bloggers reading below the line.

I hope your 'Blinded by Influence' title was aimed at the multilateral agencies rather than myself personally. I am not much of an advocate for the UN family and I share your central argument that broader research and a deeper understanding of HIV and it's drivers is critically needed. Moreover, the current lack of quality, large scale surveys and appropriate analysis is a severe hindrance to truly effective responses.

I agree that unsafe injections are a risk, particularly in relation to hepatitis B and C. My point of departure is not so much whether it's a risk

Looking at the Fort Collins example, the clinic sent out a few emails to patients in order to cover itself legally. Would you not think that the risk of exposure in that case would be very small indeed? Careless and unprofessional, undoubtedly. But a genuine health risk, I'm not so sure?

In that context, is it worth the reallocation of resources to deal with a smaller issue at the expense of a larger one?

I wouldn't use the way the 'cover all the bases' UN human resource department treat their own staff as a barometer for what is required globally. They don't travel in matatus either do they?

Again, I agree that funding is not most efficiently directed and I applaud you for trying to highlight a neglected area.

Simon said...

Hi Matthew
The title wasn't aimed at you personally, just at the way the same short, out of date, poorly researched article is cited over and over again as if each citation represents new research and additional evidence.

There is not so much a lack of research into nosocomial transmission of HIV as a lack of use of that research, a lack of investigation of procedures that result in such infections and a lack of impetus to prevent such transmission.

In fact, the three pager you cite is a response to a substantial number of articles that were published by the leading academics in the field. It was a signal to other academics that such subjects should not be discussed and, as a result, they rarely are; projects are not funded, papers are not published, existing research is not cited, etc.

It's not the lack of quality, scale and appropriate analysis that is at fault, it's also the sheer bias and prejudice that allows African people (primarily) to be treated as if they are second class humans.

If, as you agree, unsafe injections are a risk for HBV and HCV, then they are a risk for HIV, especially in countries and clinics where HIV prevalence affects so many people.

The Fort Collins example is not, as you suggest, a mere cosmetic exercise. Everybody who may have been even at a slight risk is being contacted, something that would be pretty much impossible in most East African health facilities, even if it were ever to be attempted.

Yes, the risk of exposure is low, but no, they are not leaving anything to chance. Quite different from what would happen in developing countries. My point is not that it is a high risk situation, my point is that even though it is not, something happens, unlike in countries where it would be a high risk situation.

You mention a 'smaller issue at the expense of a larger one'. Again, my point is that it has not been demonstrated which is the smaller risk, nor if the smaller one is really small and insignificant enough to allocate hardly any resources to at all, unless you believe the article you cite.

You're right, UN people don't travel in matatus, their risk is phenomenally small and they don't go to government run hospitals anyway, unless they are 'UN approved', of course. So why issue the warning at all if there is no risk? Why a belt and braces policy for UN personnel and a barearsed one for everyone else?

If I thought the issue was marginal, I wouldn't even write about it.