Sexual Distraction: Healthcare Associated HIV Transmission

Kiangiosekazi wa Nyoka gives a robust response to the claim of the Parliamentary Standing Committee on HIV/AIDS that "excessive overcrowding of remand prisoners at Segerea has culminated in unimaginable free sex in that prison". They sound almost envious. But as Kiangiosekazi wa Nyoka points out, high levels of HIV transmission does not demonstrate high levels of sexual intercourse.

This is not to deny that conditions in prisons are appalling, nor that male to male sex occurs in prisons of course, nor even that these can increase the risk of HIV transmission. But emphasizing sex, especially male to male sex, may distract attention from inhuman conditions in prisons, including conditions that also increase the risk of non-sexual HIV transmission.

The author acknowledges sexual risks that prisoners face but also reminds us about "injecting drug use (IDU), tattooing, piercing, sharing of razors, hair clippers and unsafe medical or dental care". He could also add traditional practices, including saro, blood oaths and perhaps a few other items. The author goes on to note that it is generally not possible to establish if prisoners were infected with HIV before or after spending time in prison. There is also a long list of factors that may further contribute to the above risks, resulting in the very high rates of HIV prevalence found among prisoners in many African countries.

The author rightly condemns the sloppy research used in this instance. But even careful research tends to be biased towards sexual modes of HIV transmission, especially where the sexual behavior can be painted as somehow illicit: male to male sex, extra-marital sex, sex work, etc. Just as this bias deflects much needed attention to the plight of prisoners and people on remand, the same bias deflects attention to the plight of all HIV positive people and those felt to be at risk of being infected.

On the one hand, public health programs claiming to address HIV transmission end up depicting all sexual behavior as illicit, because the majority of people being newly infected with HIV in mature epidemics do not engage in 'unsafe' sex; most of the people infected have one sexual partner, who is HIV negative; if this is really how so many people are infected by a virus that is difficult to transmit sexually, it's high time to say what it is that is so different about Africans that explain very high transmission rates. On the other hand, non-sexual transmission, such as through unsafe healthcare and various other routes, remain almost entirely uninvestigated, however strenuously the extent of their contribution is denied.

By all means address matters that are of great importance, but not at the expense of others that may be of equal importance. If people need condoms, birth control, counselling, HIV testing and all sorts of other things, they should have access to them. But these kinds of programs have been scaled up in many countries where HIV prevalence hasn't declined for years, such as Uganda, Kenya, Tanzania and others. Hundreds of thousands of new infections continue to occur every year in East Africa alone. We need to test new hypotheses about why incidence is still so high.

Huge antiretroviral (ARV) treatment programs are a testament to what can be done for those already infected. But, despite claims that 'treatment is prevention', it seems that it is not. Otherwise HIV prevalence would be increasing in countries, as more and more HIV positive people are living for longer, rather than remaining more or less the same.

Even if it were true that high levels of 'unsafe' sex is responsible for a large proportion of HIV transmission in African countries, and this has never been unambiguously demonstrated, this does not mean that all healthcare is safe; it does not mean that people do not face any risks where contaminated medical instruments have been reused and may have infected people receiving treatment. Healthcare facility conditions are terrible in East African countries, numerous reports have shown that. Therefore, it can not be guaranteed that people are not at risk of being infected with HIV and other diseases nosocomially.

I would hesitate to use even the city hospitals in East Africa and UNAIDS, rightly, warn UN employees not to use them, as they have alternatives. But Africans are not warned of the risks they may face when receiving healthcare. And the majority of people don't attend city hospitals; they attend smaller facilities, where the most senior person is a 'clincal officer', clinics where they are lucky to find anyone with proper medical training, unofficial clinics, pharmacies, unlicenced shacks that offer injections, tooth pulling and the like, all sorts of places where the possibility of HIV transmission can not be ruled out.

Kiangiosekazi wa Nyoka draws attention to a vital area of public health: non-sexually transmitted HIV. Prisoners may face such risks daily, but so would members of the general public. In Western countries we know well how risky health facilities can be when there is an outbreak of something unexpected, but there are procedures for investigating, dealing with the problems, recalling and testing those who have been exposed and treating those who have been infected. These procedures are generally not available in hospitals in East Africa; they are not even universal in the bigger hospitals. We don't have to stop talking about sex, but we also need to talk about health facility associated HIV transmission.

[For more about non-sexual HIV transmission and injectable Depo Provera, see the Don't Get Stuck With HIV site.]