Sunday, November 18, 2012

Good AIDS, Bad AIDS and African AIDS

The problem with the 'good AIDS/bad AIDS' dichotomy is that it is not just a joke. Rather, the joke was based on a real phenomenon, and it is still very much alive. People who work with HIV really do distinguish between those who were infected through ways that are thought of as being within their control, and those who are infected in ways that are thought of as not being within their control. An example of the former is sexually transmitted HIV; an example of the latter is mother to child transmission.

The HIV industry, ably (mis)led by UNAIDS and the like, urges us not to blame or stigmatize. But they also claim that the majority of infections in African countries are a result of unsafe sex, and the remainder are mostly a result of mother to child transmission. In other words, we can blame adults for their sexual behavior, and mothers for transmitting HIV to their children.

The industry is effectively saying that it is individuals' own fault, but that we must not say so. Implying that most HIV is transmitted in ways that are within the control of adults, and spending billions of dollars on intervention programs that assume most transmission is, directly or indirectly, a result of unsafe sex, reinforces the finger-pointing.

You might think that there is lots of solid evidence for the view that HIV is almost always transmitted sexually (either directly or indirectly, through mother to child transmission) in African countries. But you would be mistaken. Of course, there is a lot of evidence that HIV is sometimes transmitted sexually. But many people who may have been infected sexually may also have been infected some other way, such as through unsafe healthcare.

For example, sex workers undoubtedly face elevated levels of sexual risk. But they also face elevated levels of non-sexual risk; many visit sexually transmitted infection (STI) clinics every few months and receive a lot more injections than most other people. Men who have sex with men face elevated levels of sexual risk, especially if they are primarily receptive partners, but they too may visit STI clinics regularly. In fact, many people who face elevated levels of sexual risk may, for the reasons outlined above, also face elevated levels of non-sexual risk.

Research does tend to concentrate on sexually transmitted HIV. But there has been a fair amount of research into non-sexually transmitted HIV, even in Africa, where most funding tends to follow the western obsession with 'African' sexuality. There's a recent article in the Journal of the International AIDS Society that looks at 'non-vertical, non-sexual' HIV infection in children that cites some of the available research, though by no means all.

The authors note some appalling instances of unsafe healthcare that they and others witnessed. They list some other published accounts of infants being infected with HIV where the mode of transmission was neither from mother to child, nor was it a result of sexual abuse or even blood transfusion, and where the mother was generally not infected. In addition to poor injection safety, they note cases of surrogate breast feeding, feeding of pre-masticated food, poor hygiene and the use of unsterile healthcare equipment.

They don't make any mention of the fact that babies infected through healthcare can also transmit HIV to breastfeeding mothers, whether they are birth mothers or surrogate mothers. And some mothers and babies could be infected independently of each other. In other words, cases of infants who were not infected by their mothers may not be investigated because it is assumed they were infected by their mothers simply on the grounds that their mother is HIV positive.

But even adults who are sexually active may not have been infected sexually. One would expect infection of infants through unsafe healthcare to be rare, but the fact that it happens at all suggests that it also happens among adults and that it could far more common, because there are far more infected adults in the population. Reusing injecting equipment in a pediatric ward should be less risky than reusing injecting equipment in a ward of adults. The riskiest scenario of all could be reuse of injecting equipment in an STI clinic.

The authors even admit that there is often just not enough data collected to be certain of modes of transmission. Given the length of the paper, they also miss out on a lot of the literature, which is all the more extensive because not all research is funded by HIV industry factions. Oddly enough, though, they say that 37 children were infected in a nosocomial (hospital acquired) outbreak in Libya, whereas the actual number in the article they cite is over 400.

Other nosocomial outbreaks they mention, such as Kazakhstan and Uzbekistan, add a few hundred more. And ones they don't mention, such as those that occurred in Russia and China, bring the numbers up to the tens and hundreds of thousands. The big gap in research here, then, is research from the worst HIV epidemics in the world, which are all in sub-Saharan Africa. There have been very few documented outbreaks there and the few bits of data that have seen the light of day have remained virtually uninvestigated.

Conditions in African health facilities are often perfect for nosocomial outbreaks. Far too few facilities are run by far too few health professionals with far too little training, equipment, supplies and support. The only factor that may protect many people from hospital transmitted HIV in African countries could be the very inaccessibility of healthcare. Cotton et al also note that "Inadequate knowledge of blood-borne virus transmission risk seems prevalent among health care workers and the general population." UNAIDS are adamant that nosocomial infection rarely occurs in African countries, so most people are unaware of it. You could almost call it 'good AIDS'.

Appalling conditions in African hospitals have been widely enough reported, and blood-borne HIV risk and even transmission have occurred often enough in wealthy countries. But this has not translated into the admission that HIV may not always be transmitted sexually, even if 'Africans' do have the extraordinary sex lives attributed to them by the HIV industry. The fact that the conditions for high rates of sexual transmission were there does not mean most people were infected as a result of sexual behavior.

The main mode of HIV transmission in western countries is receptive male to male anal sex, with intravenous drug use often being the second most common mode. These are instances of 'bad AIDS', of course. We can protest as much as we like that we don't blame people for being infected with HIV, but we classify their mode of transmission as being a result of something that is within their control. We need to be very careful not to step on anyone's toes, and we certainly can not utter the words 'bad AIDS' in most western countries, but we are welcome to think what we like.

But when it comes to high prevalence countries in Africa, we don't even have to be that circumspect. Because high levels of 'unsafe' heterosexual sex need to be very high indeed to explain prevalence figures of over 20 and 30%, where the majority of people do not belong to groups known to face very high risks, simply attributing most infections to heterosexual sex is implying that it is mostly 'bad AIDS'. People infected are not just assumed to be sexually active, they are assumed to be promiscuous, and highly so. They would have to be if such high figures are really a result of heterosexual sex given known transmission probabilities.

But while we're pointing the finger, we might as well be clear that almost all AIDS could rightly be referred to as 'bad AIDS' by those bigoted enough to use such a term, implicitly or explicitly. After all, mother to child transmission is assumed to be mostly from women who were infected sexually. So let's point the finger at Africans, and let's not forget African women. We can't accept that HIV is generally a result of behavior that is within the control of adults, males and females, without at least implying that more of the blame should probably be laid at the feet of women. We may say we don't blame them, and we may adopt the 'all men are evil, all women are victims' assumption, but it's probably all 'bad AIDS' really, and far more women than men are infected.

In a way, it's a pity people no longer adopt the overtly bigoted 'good AIDS/bad AIDS' reflex, because it still lurks behind the orthodox view, that almost all HIV is transmitted through heterosexual sex in African countries. Instead, we can talk broadly about poverty, education and health, and more narrowly about gender based violence, female genital mutilation and even homophobia, without ever mentioning the institutional racism and sexism of the HIV industry, that only needs to be hidden behind a thin veil as long as no one really cares that such prejudices exist. It is because the orthodox explanation holds that almost all HIV is 'bad AIDS' that transmission rates are still out of control in sub-Saharan Africa. So let's bring back the false dichotomy and bury it properly this time, and then get on with the real work.


3 comments: said...
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themadhair said...

I was asked to post some controversy, but the truth is that all I can really do is express my wholehearted agreement with the article. There is quite a lot about HIV and AIDS that ‘we’, and by ‘we’ I refer to the human race and the collection of medical knowledge, simply do not understand about the transference mechanisms.

This article, which discusses research from as recently as 2009, illustrates the point:

A sizeable stack of anti-viral treatments that researchers attempted to develop for treating HIV were premised on the idea that the HIV virus exists (albeit briefly) outside host cells. As the previous research shows this isn’t the case.

The key take away from both articles is that there is still a shed-load we don’t know, and the effects of poor healthcare on the spread of HIV is still an unknown factor that cannot be blamed or mere promiscuity.

Simon said...

Thank you for your visit. I suppose comments don't have to be controversial to be instructive! That's a good blog and it's always interesting to hear simple accounts of the fact that little is straightforward when it comes to viruses and the immune system.