The open letter sent to Michel Sidibé, Executive Director of UNAIDS, Margaret Chan, Director General of WHO and Jim Kim, President of the World Bank received a response that is the equivalent of answering a question by referring back to the very data that prompted the question in the first place. Between one sixth and one third of HIV positive children under 5 years old have HIV negative mothers in the four countries where it was deemed important enough to test for this phenomenon.
Clearly, three of the top institutions involved in health and HIV in developing countries demand a better reason to investigate safety in health and cosmetic facilities, where skin-piercing procedures may be transmitting HIV and other blood-borne diseases. The reuse of unsterile injecting and other equipment has been identified as a risk factor on many occasions, without this resulting in African people being warned about the non-sexual risks they and their children face. The status quo has been to claim that health facilities are safe and that almost all HIV transmission is a result of 'unsafe' heterosexual sex.
The above esteemed personages, apparently, "recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission". However, their currently available data, and even their data collection instruments, are designed to diminish the possible contribution of non-sexually transmitted HIV to the most serious epidemics in the world. So they do, as they claim, make 'explicit reference' to non-sexual transmission, but they expect us to believe that it only accounts for a very small proportion of all transmission, about 2.5% for a country such as Kenya.
Whether they are right or wrong, we can only guess. Nosocomial infections, also known as 'hospital acquired infections', are certainly a recognized phenomenon in Western countries. A recent article about the UK health service finds that in one year, 70 people had operations on the wrong part of their body and 161 had foreign objects left inside their body after an operation. But are such data even collected in countries like Kenya, Uganda and Tanzania? Not too often, I suspect. Another article claims that Kenyan doctors are striking because of poor health care conditions; whether that's the real reason they are striking is another matter, but they should know more than anyone about conditions (aside from patients, I guess).
In the US, a man is said to be suing the blood service, alleging that he received HIV contaminated blood and is now HIV positive. He was having a coronary bypass, a kind of operation that is not too common in African countries; but less healthcare is not a solution to the problem of unsafe healthcare. In addition, a pharmaceutical company is recalling products that have been linked to a national outbreak of meningitis that has killed 28 people. Despite protestations from UNAIDS, WHO and the World Bank that this kind of thing hardly ever results in HIV transmission, it is likely that such adverse events are far more common in Africa, where some countries only have 30-40% of the trained personnel they need, with frequent breaks in provision of supplies and equipment vital to ensure adequate infection control.
Aside from Kenyan doctors' apparent disgust at healthcare facility conditions, there are other mentions of possible risks to patients from time to time in the press. Patients in a hospital in Homa Bay (one of the highest prevalence areas in Kenya) have been asked to buy their own medicine before receiving treatment. One source said they had not received 'medical supplies', and that the supply is very erratic. There's mention of surgical blades, gloves and disinfectant. But it is commonplace for pregnant women to bring to the hospital two sets of gloves, razor, cotton wool and other things needed to give birth. Whether they are used or not is unclear.
A district official in Kiteto, Tanzania, has expressed 'concern' over the poor conditions found in some health facilities. Apparently patients have to purchase their own water, but most facilities don't have access to water for cleaning much of the time, let alone drinking water. The article is not clear about exactly how bad conditions are but it sounds like facilities are sometimes not used, which may give people some protection from unsafe healthcare, but at great cost to the health of patients.
The above institutions are much more comfortable with articles such as this: "Tanzania: Unsafe Sex Rampant - Study". The article gives a few snippets from the Demographic and Health Survey, which will probably not be made available to the public in full until the data is at least a couple of years old. But we don't get anything to compare it with, so we don't know how serious it is. We can expect 'unsafe sex' to be 'rampant' among sex workers, but we don't know why so many Tanzanian sex workers are infected with HIV when sex workers from other countries are hardly ever infected unless they have other risks, such as intravenous drug use. And there are many people who are not sex workers, yet they seem to face even higher HIV risks, something WHO, UNAIDS and the World Bank are happy to explain away as 'unsafe sex', without bothering about evidence.
Changing the story from 'there is no problem' to 'the problem is very small' is not a real change. WHO, UNAIDS and the World Bank are still refusing to address the real reasons for exceptionally high rates of HIV transmission in some parts of some countries in Africa, putting it all down to unsafe sexual behavior. But sexual behavior does not now, and has never correlated with HIV prevalence figures. Non-sexual risks have not been properly assessed in high prevalence countries, as if the whole issue is too embarrassing for the HIV industry. But these institutions have failed to have any impact on HIV transmission; what could be more embarrassing than that?