Wednesday, January 25, 2012

Deceived and Misled, HIV Positive People Can Only Speculate About Their Infection

I was intigued by the title of a Kenyan newspaper article: "When a Woman Feels She Is Not 'Rightfully Infected'". I thought that maybe someone was asking how they could have been infected with a virus that is not easy to transmit sexually even though they have never had unsafe sex, very little sex or perhaps no sex at all. Demographic and Health Surveys usually find that a considerable number of people are infected with HIV even though they have no obvious sexual risks. Non-sexual risks are rarely considered and it is usually assumed that people have lied about their sexual behavior.

Anyhow, the article doesn't go that far. A HIV positive woman reflects on the fact that she didn't have enough sex during her marriage to warrent HIV infection. Her husband was working in South Africa and he only came home every six months, which is the only time they had sex. After 22 years of marriage, the woman was diagnosed HIV positive and found that her husband had another wife. Was her husband infected? We are not told. We also don't know if he was infected sexually, whether he infected his wife (the one writing the article) or whether she was even infected sexually.

Leaving aside the fact that the man had another 'wife', in order to establish how someone is infected it is necessary to work out what risks each HIV positive person faces. Even if the man was infected sexually, that does not mean he infected his first wife. She deserves to know how she became infected because if it turns out that her husband is not, and this is commonly the case, it will be implied that she was infected by having sex with someone who was not her husband. This is the HIV orthodoxy: 80-90% of HIV is heterosexually transmitted in medium and high prevalence African countries, though nowhere else. The consequences can be disasterous, with women thrown out of their homes, beaten, dispossessed, even killed.

Far more women than men are infected with HIV in high prevalence countries. Far more men than women engage in 'unsafe' sex. In discordant couples, those where only one partner is infected, it is as often the female partner that is infected as the male; it's approximately 50/50. when genetic typing has been carried out, many couples where both partners are infected are infected with a different subtype of the virus. In other words, one probably didn't infect the other. And even where both have the same subtype, they might not have both been infected sexually. Perhaps neither were infected sexually.

(On the subject of the ratio of male to female prevalence, it's also worth noting that male high HIV prevalence groups are not part of the general population. For example, many men who have sex with men don't have sex with women. Most intravenous drug users are men. Even prison populations, among which prevalence is said to be remarkably high, probably face serious non-sexual risks, such as tattooing, oathing, traditional medicine, intravenous drug use, etc. The actual percentage of HIV positive males who are infected heterosexually is probably a lot lower than the percentage of infected males.)

It may be a long shot, but it's worth checking who infected whom because if it's not the 'obvious' person, it needs to be established how the virus is being transmitted. If someone doesn't often have sex, only has sex with someone who is HIV negative, or has never had sex at all, they should not be infected. There are likely to be non-sexual risks that need to be investigated, particularly healthcare related risks. It's not acceptable to assume that people who are infected with HIV and are African are necessarily liars. But this is generally what happens.

The two women in the article discuss the fact that some people who have little sexual exposure can be infected while those with a lot can remain uninfected. But they seem unaware that some people face substantial non-sexual exposures. They are right that someone could be infected though having sex with a HIV positive person just once; right in theory. But it's highly unlikely. And highly unlikely occurrences like that give rise to few infections. Yet millions of people in some African countries are infected. Something that is highly likely to transmit HIV occurs frequently enough in some countries to give rise to hyperendemic HIV.

So what is it? Unsafe healthcare? Unsafe cosmetic or other skin-piercing procedures? To reduce HIV transmission, we need to know how it is being transmitted. By assuming that it is always sexually transmitted we end up implementing, at best, prevention strategies that may have no influence on non-sexual transmission, whatever influence they have on sexual transmission. At worst, we are just standing by while people become infected and go on to infect others.



Anonymous said...

Nice blog. Check this out.

Insertive (male) penile-vaginal intercourse - 0.05% probability

Blood transfusion - 90% probability

I'd like to donate blood but I'm afraid of getting infected.

Simon said...

Thanks for your comment. There is a lot of possible variation in transmission probabilities and receiving a blood transfusion is not the same as donating blood. However, HIV and other blood borne diseases can be transmitted through donating blood:

Petit Poulet said...

In the randomized clinical trial of circumcision and HIV published by the folks at Johns Hopkins, they had several men who became infected despite their claim that they had not had sexual intercourse. The researchers blew them off and assumed that they were lying. These researchers are influential in making policy. Pretty scary.

Simon said...

Quite true Petit Poulet, people seem to get away with saying ridiculous things as long as they confirm existing prejudices.

Anonymous said...

My wife is an A&E nurse at Aga Khan, a top private hospital in Nairobi. I'm really afraid of her getting infected on the job but she really loves her job. She once got pricked as a student at nursing school but everything turned out okay. We both tested negative before getting married and we don't use condoms. What should I do?

Simon said...

The best thing to do is get clear advice from people who work with infection control, such as those at Aga Khan. The fact that you and your wife are aware of the risks is probably the most important way of avoiding HIV and other blood borne diseases. Needlestick injuries are common in hospitals, including Western hospitals, and the transmission probability is low.

A far higher risk is that a health professional will reuse contaminated equipment that may have been used on someone with HIV, hepatitis or some bacterial infection, and infect other patients. Luckily, healthcare workers themselves have easy access to post exposure prophylaxis (PEP) and good counselling services, at least in hospitals like Aga Khan. But it's the patients who face higher risks, often risks that health professionals refuse to accept exist. The risk to your wife should be small and manageable by her. The risk to you should be negligible.

But awareness of the risks and how to avoid them is the most important way of preventing such transmissions! Without acknowledging that they occur, nothing will be done to reduce the risk or even to inform HIV positive people that such non-sexual risks exist.