Monday, July 4, 2011

Do Different UN Agencies Talk to Each Other? Guess Not.

The United Nations Foundation is currently trumpeting their success in reducing immunization related infections of hepatitis, HIV and other blood borne diseases. This has been achieved through increased injection safety, especially through the use of auto-disable syringes, which cannot be reused.

This is excellent news. The Measles Initiative and GAVI (Global Alliance for Vaccines and Immunization) say reduction in infections has resulted from a reduction in the reuse of syringes. Reuse is now practically zero, apparently. In contrast, an estimated 39% of injections given globally in 2000 involved the reuse of unsterilized equipment. That's globally, not just in African countries, where health care conditions are dire.

But the Foundation's claims are less impressive when you look at UNAIDS' estimate of the contribution of unsafe medical practices to HIV prevalence in high and medium prevalence countries. They estimate that all unsafe medical practices, from blood transfusions to reuse of injecting equipment, make a maximum contribution of 2.5%, possibly a lot lower.

It's not unusual for different UN agencies to flatly contradict each other, even for communications from the same agencies to do so. But almost all of UNAIDS' publications about HIV in high prevalence countries have emphasized the role of sexual behavior, claiming that 80%, even 90% of all transmissions are a result of unsafe heterosexual sex. Most of the remaining 10 or 20% is said to come from mother to child transmission.

This leaves only a small fraction to be accounted for by the biggest causes of transmission in non-African countries, men who have sex with men and intravenous drug users. But also, non-sexual transmission through unsafe medical and cosmetic procedures, which occurs everywhere outside of Africa, is not considered to be a risk at all in high HIV prevalence countries.

Of course, HIV prevalence should be low among children receiving measles injections, so the risk of transmission through unsafe injections should be lower than among adult populations, where HIV prevalence is often very high. And prevalence is particularly high among young, sexually active females. So it is to be wondered how much HIV could be transmitted among pregnant women, sex workers and even people regularly attending STI clinics and any other type of health facility.

Another contradictory aspect of the significant declines in HIV prevalence, which date back to the 90s and continue right up to the present, is that UNAIDS has been attributing them to changes in sexual behavior. That's OK, declines could result from a combination of sexual behavior change and improved injection safety. It's just that UNAIDS doesn't normally mention injection safety.

In fact, UNAIDS often go to great lengths to deny the role of unsafe health care in HIV epidemics in African countries. They effectively undermine the entire article by the United Nations Foundation. And the few people who have tried to raise the issue of non-sexual HIV transmission over the past 10 to 15 years have either been slapped down or ignored.

Sensible people know that HIV is transmitted in a number of ways and that sexual transmission only accounts for some of it. But global HIV policy is not written by sensible people. It's written by people who think that mentioning the possibility of non-sexual transmission will result in people not taking precautions against sexual transmission and perhaps even avoiding medical facilities.

However, if people face the risk of being infected with HIV and other diseases in health facilities, they should take precautions against this risk. So they need to be informed about all the risks they face and about how to avoid them. Why is it so important that Africans avoid sexual risks but not non-sexual risks? This does not make sense and it probably results in hundreds of thousands of avoidable infections every year.


No comments: