UNAIDS' Loss May Be Kenya's Gain

It sounds like Kenya is getting more serious about non-sexually transmitted HIV, at last, particularly where the virus is being transmitted through unsafe healthcare. So far, it has been mentioned that healthcare professionals face some risk of being infected, especially where safety procedures are not strictly followed. But there is also an even higher risk to the patient. If equipment is reused without adequate sterilization, one or more patients may be infected with HIV, hepatitis and various other blood-borne diseases.

There's a relatively lengthy article in Africa's Business Daily about the training that will be given to health professionals in the new School of Phlebotomy, opening soon in Nairobi. While risks to patients are not explicitly mentioned, it is clear from a number of comments in the article that they will benefit the most if this facility is successful in its aim of training 25 people every fortnight from April onwards. Some of the sponsorship comes from Becton Dickinson, one of the world's leading producers of injecting equipment. But worth far more than the money they are contributing is the acknowledgement that there is a problem with unsafe healthcare; and equally, that there is a cheap solution to it.

This acknowledgement, which follows years of denial by international HIV institutions, should fit well with another proposed change in Kenya, mentioned in my last blog post; the idea that HIV needs to be integrated into healthcare as a whole. To this end, the government health departments and the National Aids Control Program are in agreement that there can no longer be parallel health systems, for HIV on the one hand and for everything else on the other. This is wasteful and particularly untenable at a time when HIV funding is being cut. (Unfortunately for almost every other area of health, funding was cut in the 1980s and has never recovered.)

Despite all the gloom about reduced HIV funding and the need to rethink how the disease should be approached if most other health issues are not to continue to be ignored, there are some very promising trends in public health in Kenya. Better infection control through improved training, equipment and support is a very good start. But another highly successful area in HIV prevention has been prevention of mother to child transmission (PMTCT). There are far more women in need of this form of treatment than are currently receiving it, but very wide coverage could cut transmission to the sort of low levels seen in Western countries.

There are many expensive distractions, such as male circumcision and potentially harmful hormonal contraceptives, both of which could be suspended until they have been shown to be effective in the case of male circumcision and safe in the case of Depo Provera and similar birth control methods. On the plus side, greater use of condoms would obviate the need for both of these strategies; condoms are cheap and, as circumcision and birth control enthusiasts have been forced to point out, neither of the two expensive options are of much use on their own.

There is a lot of talk about the 'dual need' to reduce unplanned pregnancy rates and at the same time, eliminate the risk of transmitting HIV and other sexually transmitted infections (STI); condoms meet this dual need. Some may view condoms with suspicion, but Depo Provera without condoms carries a far higher risk than condoms on their own, or even, arguably, nothing at all. Birth control enthusiasts seem to think the risk of unplanned pregnancy is so important that an increased risk of HIV infection is a price worth paying; but efforts to reduce MTCT seem a little self-defeating if risks to mothers are being increased.

In fact, far better than passively waiting for mothers to become infected and then attempting to intervene with PMTCT is reducing infections among women, which suspension of the use of Depo Provera could contribute to, perhaps significantly. Male circumcision is also likely to increase HIV transmission from males to females (even if it reduces infection from females to males); so again, suspending the strategy until these matters have been clarified could reduce MTCT by reducing the number of infected women. The amount of money saved by not continuing with these highly suspect programs would be small compared to the amount saved by not infecting people by continuing them; and the effect is additive!

What about the high risk groups so beloved of journalists and those who need to attract the attention of journalists? Well, they will also benefit from improvements in the safety conditions in health facilities. Those who regularly attend STI clinics, such as sex workers, their clients, men who have sex with men and perhaps intravenous drug users; people regularly receiving healthcare for STIs, who may face far higher risks of being infected with HIV non-sexually than sexually. Just think about it: many of them end up in the same clinics. They may appear to be at risk of being infected with HIV through their work or lifestyle, but there are also additional non-sexual risks.

This may be the first time in the history of HIV that countries with high prevalence get to make their own decisions about HIV (and health as a whole) and set their own priorities. It is possible that Kenya is already way ahead of the now faltering international HIV institutions, who, in the absence of the massive levels of funding they have become used to, have taken to wandering around like clapped out old druggies in search of a pusher who may never return.

[For more about non-sexual risks for HIV transmission, see the Don't Get Stuck With HIV site and blog.]