Tuesday, December 4, 2012

HIV and Prevention: Where There's Money, There's a Way?

The WHO (World Health Organization) finds that Pakistan has "high rates of unscreened blood transfusions and a very high demand for therapeutic injections and poor infection control practices in hospitals and clinics nationwide", which can lead to transmission of HIV and other diseases. It's a big step for the WHO to talk about non-sexually transmitted HIV in this way, and I hope their 'concern' also extends one day to sub-Saharan African countries. Because, even if infection control practices are a lot better in African countries than they are in Pakistan, and that's a very big if, the risk of healthcare transmitted HIV is still high in Africa because of the huge numbers of HIV positive people in some populations.

UNAIDS once pooled together some available figures on HIV and unsafe medical injections in a group of African countries, but they came to some fairly half-hearted conclusions about the issue. They found that "receiving multiple medical injections is significantly positively associated with being HIV-infected, for both women and men. Ever having received a blood transfusion also tends to be positively associated with being HIV-Infected". They further find that "few adults perceive the risk of HIV infection from having injections or blood transfusion". After many years and hundreds of millions of dollars of HIV education, it seems hard to believe that people are not aware of non-sexual risks, especially from contaminated blood and unsafe healthcare.

The UN itself is so acutely aware of the risks of hospital transmitted HIV that they have issued a booklet for their own employees, warning that "Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." The problem is that UNAIDS' HIV prevention interventions do not warn Africans about these risks. Instead, Africans are told that 80% of HIV transmission is a result of unsafe sex (and about 18% is a result of mother to child transmission).

The totally misguided mass male circumcision programs (also called 'safe' male circumcision or 'voluntary' medical male circumcision) have a particularly nasty sting in the light of the above considerations. If HIV is not almost always transmitted sexually, circumcision will not prevent as many infections as enthusiasts are projecting. But also, conditions in sub-Saharan African health facilities are poor enough to warn UN employees against, so how can they provide in excess of 20 million circumcisions safely? The simple answer is that they can't, the UN can not ensure that the operations will be safe, not safe enough for their own employees, anyhow.

The oft-cited randomized controlled trials of mass male circumcision have already made it clear that it is not circumcision on its own that explains differences in transmission rates in circumcised and uncircumcised populations because HIV prevalence is as often higher among circumcised men as it is among uncircumcised men. If it protects against sexual transmission of HIV, it only does so sometimes. Apparently (Hillary) Clinton has a "blueprint for reaching an AIDS-free generation which includes throwing more drugs at the problem and circumcising men.

Making antiretroviral drugs available to everyone who has a clinical need for them is vitally important, and it has proved its worth by keeping millions alive who would otherwise have died; it has also ensured that most HIV positive women in rich countries and a majority of women in poor countries can give birth to HIV negative babies; some of them even live to raise their own children. But if we are to make drugs more widely available in order to reduce HIV transmission, we need to know which people to target. Assuming that HIV is almost sexually transmitted, as mass male circumcision programs do, will not work. But perhaps now that there is so much money tied up in reducing HIV transmission through mass antiretroviral drug administration, we will acknowledge that not all Africans are sexually promiscuous and that a substantial proportion of HIV transmission can be cut by improving conditions in health facilities.

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


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