Tuesday, November 27, 2012

UNAIDS: Knowledge Can Be Powerful, So Let's Keep it to Ourselves

A fairly typical UNAIDS document on modes of HIV transmission in West Africa finds that "the percentage of new infections due to unsafe medical injections is less than one percent (0.4%, range 0.1%-0.9%) and that the percentage due to contaminated blood transfusions is even lower (0.1%, range 0.0%-0.5%). The percentage due to unsafe medical injections is somewhat lower than the 1-3% found by other studies." Similar figures are extracted from UNAIDS data for high HIV prevalence sub-Saharan African countries that make unsafe medical injections sound like a very unlikely contributor to serious HIV epidemics.

UNAIDS seem intent on attributing the vast majority of HIV infections in African countries to 'behavior', mostly sexual behavior. In fact, most transmission is attributed to heterosexual behavior among people who do not appear to face particularly high risks. So how does a low risk of infection result in massive rates of infection? Only by assuming massive levels of unsafe sexual behavior, levels that are not detected by empirical investigations into sexual behavior and other risks. Using UNAIDS' methods, it is impossible to explain the kinds of prevalence figures found in some African countries without positing ridiculous levels of sexual behavior.

That's how the story goes when UNAIDS are telling Africans and non-Africans about the most serious HIV epidemics. But when they are warning UN employees who are working in African countries, in a booklet given to all UN employees called 'Living in a World with AIDS', they say quite different things. For example they say "In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections." I'm assuming that below 1% does not constitute a 'notable share'. UNAIDS go on: "Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care."

That must be a great source of relief to UN employees. As for Africans, they are told the other story, the one about 80% of HIV transmission being a result of unsafe sex. They are not told that they face non-sexual risks in health facilities. That way, it's possible to blame Africans themselves for high rates of HIV transmission. Most of the remaining 20% is said to be a result of mother to child transmission, and while we don't 'blame' mothers for causing this, poor things, they were probably forced to have unprotected sex with their evidently HIV positive and philandering husband, many women are infected in the second or third trimester, or some time after giving birth, and many of them have HIV negative husbands.

Living in a World with AIDS also says "we all have the right as UN system employees to essential prevention tools, including access to condoms, first-aid kits, new syringes and sterilized equipment for medical care, and safe blood supplies." Therefore "Because safe injection practices are not followed in all healthcare settings and it may not always be possible to purchase sterile injection devices, the WHO medical kit that is made available to all UN agencies includes disposable syringes and needles." UN employees can certainly breathe a sigh of relief because "If we receive medical care from the UN system medical services or from a UN-affiliated health-care provider, we can be confident that every effort has been made to ensure that injecting devices used to administer a shot are sterile and will not expose us to HIV." But every Service Provision Assessment carried out in an African country makes it clear that ordinary Africans do not have the same rights as UN system employees.

The forward to 'Living in a World with AIDS' notes the importance of "stamping out any stigma and discrimination associated with HIV, and speaking openly about HIV transmission", but the overall impression given is that UN employees should not be stigmatized or discriminated against. As for non-UN employees, we don't have to resort to the term 'bad AIDS' to emphasize the fact that HIV is almost definitely their own fault; except if they are an infant. But if they are a woman it's probably their own fault, as is the HIV infected infant. In fact, women are probably also responsible for tempting men, prostituting themselves or otherwise being careless or engaging in some kind of sinful or criminal behavior.

We are also reminded that "It is important to bear in mind that HIV is not easily transmitted. In the case of household employees, we assume that they will not be having sex with our family members, will not be sharing needles with them or giving them blood and will not be breastfeeding our children." That is important for everyone to bear in mind, not just UN employees. So if your partner is infected and you are not, or if your baby is infected and your partner is not, you don't need to assume that your partner has almost definitely been having sex with someone else, or that your baby has been breastfed by someone who is HIV positive, or has been sexually assaulted. But strangely, UNAIDS doesn't have much else to say about HIV positive infants whose mothers are HIV negative.

Knowledge can be powerful, as the booklet says. And there is a lot of sensible advice for UN employees. The problem is that this advice is not given to people in high HIV prevalence countries, where conditions in health facilities are appalling and ordinary people, those most at risk of being infected with HIV, do not receive free supplies of syringes and other equipment that UN employees get, and do not have the option of choosing "UN-approved medical facilities". UNAIDS are aware that "Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission." But while "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", what about people who are not in the 'UN system'? Shouldn't they also be warned of the risks?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


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