Sunday, September 18, 2011
The belief that generalized HIV epidemics, such as those found in some sub-Saharan African countries, originate from and are driven by extremely high levels of 'unsafe' sexual behavior has always been undermined by a number of considerations. (Generalized epidemics are those where a significant proportion of the general population is infected, rather than members of high risk groups, for example, men who have sex with men and intravenous drug users).
Sexual behavior is not that different in countries with high and low HIV prevalence; levels of 'unsafe' sex would need to be higher that is possible for human beings to explain prevalence that is substantially greater than 1% of the sexually active population; and there has been no recorded massive increase in 'unsafe' sexual behavior in countries that experienced the worst epidemics, followed by a massive decrease in the same behavior a few years later.
These are embarrassments to the HIV industry, which has been pushing this theory, sometimes called the behavioral paradigm, for more than twenty years. But there is a far better set of factors that have been little studied, though enough to see that they shed far more light on rapid transmission of a virus that is difficult to transmit sexually.
Amongst these factors is blood transfusion. When it was realized that transfusion of blood and use of blood products was one of the most significant modes of HIV transmission in the 1980s, many countries made requisite changes in their health services. But countries with low (and falling) health spending often didn't make these changes, or only did so partially.
In 2006, William H. Schneider and Ernest Drucker published a fascinating history of the use of blood transfusions in Africa and their possible contribution to the HIV pandemic, particularly in its early years. They estimate that "approximately 20 million transfusions [were] done in sub-Saharan Africa during the 1980s" and that "30 to 40 million transfusions occurred in sub-Saharan Africa in the period 1950–1990."
It is still the case today that HIV prevalence is far higher in urban than rural areas. Indeed, in some parts of rural Tanzania and Kenya, HIV is virtually unknown. In South Africa, Lesotho, Malawi and other countries, HIV has been shown to cluster, especially close to main roads and even health facilities. It's worth remembering that 70-80% of people in many African countries live in rural areas.
Transfusions, also, are mainly carried out in urban areas. According to Schneider and Drucker, they probably always have been. There is also some evidence that transfusions and donations were more likely in the military, police, government employees and among mine workers, groups that have suffered from especially high rates of HIV.
Even the finding that transfusions were more likely among wealthy colonials brings to mind the fact that HIV is said to have peaked and begun to decline among white South Africans before it hit the black population.
It was also in the early years of the pandemic that the role of other medical procedures was recognized, such as injections and other skin piercing activities. While this also led to changes in practices in wealthy countries, conditions in health facilities in developing countries haven't changed so quickly. And shortages in personnel, training, equipment and supplies can result in numerous lapses in infection control.
UNAIDS insist that unsafe health care only contributes to a maximum of about 2.5% of HIV transmissions in African countries and the rest is accounted for by heterosexual sex and mother to child transmission. But UNAIDS also warn UN employees that they can't guarantee the safety of health facilities in developing countries. If this is so, Africans are also entitled to know that their health facilities are not safe.
"Extra precautions should be taken, however, when on travel away from UNapproved 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."
There are two separate instances of institutional racism here: firstly, the assumption about African sexuality and levels of 'unsafe' behavior being enough to explain HIV prevalence levels hardly ever seen among non-African populations; and secondly, warning UN employees about the risks of unsafe healthcare and how to avoid them while telling Africans that they don't need to worry about non-sexual risks.
Schneider and Drucker's findings should have triggered an investigation into historical and current conditions surrounding blood transfusion and donation. Other skin piercing practices in health and cosmetic facilities need to be investigated. Those most at risk need to be warned of all HIV risks, non-sexual as well as sexual. And people need to be told how they can protect themselves. Only then will HIV transmission fall enough for the virus to eventually be eradicated.
[For more information on blood-borne transmission of HIV and how to avoid it, see the Don't Get Stuck With HIV website and blog.]