Sunday, March 18, 2012

Expanded Healthcare Without Increased Safety Could Spread HIV

Kenya's Public Health and Sanitation Minister, Beth Mugo, has thanked Kenyans for their prayers, which she says healed her breast cancer. But it sounds like she neither trusts prayers nor Kenya's health services because her cancer was detected early and treated in the US. I'm happy to hear that she is now recovering and has also had the opportunity to find support for a cancer center in Kenya. But I certainly don't blame her for not trusting Kenya's health services, which are, for many people, appalling; for others, they are too expensive to even be considered.

We are told that in the capital's Pumwani Maternity Hospital, patients "have to buy their own syringes, needles, cotton wool and maternity pads". As to whether these items are then used properly and only once by the badly motivated, inadequately trained, poorly paid and fairly rare health professionals, we can only guess. These and other worrying details are not new and have been well attested in documents such as the Kenyan Service Provision Assessment. The UN also warns its employees about the dangers that can be faced when using health facilities that are not 'approved', the same facilities that most Africans (aside from people like the minister herself, of course) must rely on.

The article goes on to say that "60 per cent of mothers in sub-Saharan Africa do not have a health worker present during childbirth". It's hard to know whether this is a bad thing or a good thing. Viruses such as HIV tend to be far more common in urban areas, where more people have access to health facilities. In some countries, such as Ethiopia, women who have access to healthcare workers and facilities are many times more likely to be HIV positive than those who give birth at home. HIV prevalence nationally is 2.4% in Ethiopia, compared to over 6% in Kenya, where healthcare access is far higher. But also in Ethiopia, HIV prevalence is only 1.2% for those mothers who were not attended to by a health professional, compared to 9.9% among those who were.

Expanding access to healthcare, as is being done in Senegal, would only be a good thing if those services were safe. But Senegal doesn't have anything like HIV prevalence levels found in Kenya, or even in Ethiopia. And countries where access to healthcare is relatively high, such as South Africa, Zimbabwe and Botswana, have some of the worst HIV epidemics of all. A study carried out in Malawi even found that HIV prevalence was highest closer to health facilities. Expanding healthcare sounds like a no-brainer until the issue of safety is considered; without ensuring higher levels of safety, expanding healthcare could increase transmission of bloodborne and other diseases, including HIV.

[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]



Anonymous said...

Kenyan sex workers top HIV infection list with a prevalence rate of 34%.

HIV prevalence rate among Majengo prostitutes drops from 10% to 1.5% over 2 decades.

No Nairobi prostitute turns HIV positive over a 3-yr study.

So, who's right?

Anonymous said...
This comment has been removed by a blog administrator.
Simon said...

Thank you for the links, perhaps there's something of the three blind men and the elephant, with one catching hold of the tail, one the torso and one the ear?

One of the problems seems to be the overwhelming concentration on sexual risk, to the exclusion of all other risks, some of which are very high for sex workers in particular.

Also, I'd question the average figures for numbers of clients, numbers of sex workers, etc. But all these research projects have to compete for dwindling funds and they have to produce results that please those in control of the money, as well.

Petit Poulet said...

You also have to consider the safety within a research setting versus in the real world. Bailey, on of the most vocal circumcision enthusiasts, found the complication rate for circumcisions performed within the medical system to be 17.7% and 35.2% outside the medical system. When he controlled the study, the complication rate was much lower.

I have to wonder if the reason that HIV infections decreased in a prospective trial that aggressively looked for and treated STDs was because the treatment was through the study, which as outside funded, and used clean needles.

The best studies in science will not translate to the real world if the real world doesn't have the resources available in the study setting.

Simon said...

I always wondered how adverse event rates could be so low when that study found them to be so high. Interesting to note your use of the word 'aggressive'. Even after that study, Bailey and his friends conclude "Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention." But he seems to think safety is mainly a problem in non-clinical settings.