Thursday, February 2, 2012
"One consequence of the global HIV/AIDS pandemic has been the emergence of a broad awareness of the potential role of syringes in the transmission of infectious diseases", write Nicola Bulled and Merrill Singer in Aids and Behavior. Indeed, several countries experienced sudden drops in HIV incidence, the annual rate of new infections, relatively soon after the virus arrived. These drops occurred long before HIV prevention interventions became widespread, and they are likely to have resulted from the very phenomenon Bulled and Singer note. But more still needs to be done as there is a lot of evidence that bloodborne diseases may still be transmitted through unsafe healthcare.
Of course, HIV industry cant about changes in sexual behavior is legendary. But those changes, if they ever occurred, must have done so much later, particularly if they had any causal connection with the interventions claimed to have turned around some epidemics and stopped others in their tracks. While some sexual behavior change may have occurred, perhaps even as a result of these interventions, the most significant changes probably took place in hospitals and other health facilities, and would have had little to do with sex.
Therefore, the massive increase in 'unsafe' sexual behavior that is said to have given rise to the worst HIV epidemics in the world probably never occurred. which means that the equally massive decreases in sexual behavior needn't have occurred either. But while Bulled and Merrill are right in their statement, the HIV pandemic is still blamed on sexual behavior, and in countries where prevalence is highest, it's blamed on heterosexual behavior. In contrast, where HIV prevalence is not so high, it is known to be more closely related to anal sex and intravenous drug use.
Interestingly for those who believe that HIV is just one disease out of many, and nowhere near the biggest health threat that people in high prevalence countries face, is that use of unsterile injecting equipment is also linked with transmission of hepatitis B and C, Leishmaniasis, malaria and other diseases. In other words, countries where unsafe healthcare is the norm have many reasons to identify dangerous practices and improve infection control, rather than passively accepting UNAIDS' assurance that a very small percentage, perhaps one or two percent of HIV transmission, is a result of unsafe healthcare.
Far from a build-up of unsafe sexual behavior, the authors don't even mention sex, which is unusual in the literature. Instead, they describe a climate of increasing use of injecting equipment throughout the 20th century, in and out of health facilities, by professionals and non-professionals. Through unsafe injecting practices, many diseases can spread to many countries, even many continents.
The authors even mention a myth that has been propagated by numerous parties, including the US Centers for Disease Control (CDC, though they have partially retracted the myth); that HIV dies in seconds outside the human body: it doesn't. HIV and hepetitis B and C can, "given ideal conditions, survive outside the human body for several weeks". They say "HIV has been found to survive in syringes at ambient temperatures for up to 6-weeks". But unsafe healthcare practices are unlikely to require anything like six weeks: instruments could be reused straight away, and many times each.
None of the above denies that HIV can be sexually transmitted but it does put a question mark over UNAIDS' claims about epidemics being almost entirely sexually transmitted in African countries, where some of the most appalling health facility conditions can be found. And UNAIDS don't even believe their own propaganda anyway, because they give the following warning to UN employees:
"The most efficient means of HIV transmission is the introduction of HIV-infected blood into the bloodstream, particularly through transfusion of infected blood. Most blood-to-blood transmission now occurs as a result of the use of contaminated injection equipment during injecting drug use. Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved 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."
If HIV and other bloodborne pathogens are a danger to UN employees in health facilities, this is also a danger to Africans. They need to be warned, just as they are about sexual risks. Otherwise they will be unable to identify risky practices and unable to take steps to avoid them. The authors conclude that "From a public health standpoint, identifying syringe use patterns and their role in specific syndemic events, however, is critical because syringe use presents a discrete point of potential intervention as well as a pathway for the spread of diseases outside of their historic range."
A number of harm reduction measures are recommended, along with improved supplies, education, support to clinical facilities and other steps, which the authors point out are already known. But being known to UNAIDS, WHO and others who wield a lot of power in global public health has not readily translated into action. After three decades of getting to understand HIV better, the extent of non-sexual HIV transmission, particularly in health facilities, is in serious need of investigation. There is a lot that can be done; if various international players feel unable or unwilling to do anything, perhaps African countries need to go it alone.
[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]