Tuesday, June 17, 2014

HIV in Namibia: What You Don't Seek, You Won't Find

There was no mention of HIV in Namibia's 1992 Demographic and Health Survey and AIDS was only mentioned in passing. HIV prevalence had more than doubled since 1990, from 1.2% to 2.6%. But by 2000, when their second DHS was carried out, prevalence is estimated to have reached 14%, five times higher in less than a decade. So what areas of HIV had Namibia addressed during this time? The following table is from the 2000 DHS (p155, Table 11.1) :
Ways to avoid HIV/AIDSWomenMen
Does not know AIDS or if it can be avoided7.94.0
Believes no way to avoid4.02.3
Does not know specific way0.30.0
Abstain from sex34.740.5
Use condoms80.987.0
Have only one sexual partner31.028.5
Avoid multiple partners7.410.5
Avoid sex with prostitutes1.03.3
Avoid sex with persons who have many partners1.62.5
Avoid sex with homosexuals0.20.3
Avoid blood transfusions1.31.0
Avoid injections0.80.6
Avoid sex with IV drug users0.60.5
Avoid sharing razors/blades2.22.6
Other including avoiding kissing/mosquito bites/traditional healer1.81.6
Aside from over 80% of people knowing about using condoms against HIV, which is good, knowledge about other ways of avoiding infection, even sexually transmitted HIV, ranges from poor to negligible. But the fact that less than 1% of people know that unsafe injections can transmit HIV is extremely worrying, considering risks from unsafe injections was well known at this time. More people are aware of the risk of transmission from razor blades than the risk of blood transfusions.

Even Jacques Pepin, who strenuously denies a significant role for unsafe healthcare in high HIV prevalence African countries, admits that 5% of HIV may have been transmitted via these routes globally in 2000, which means the contribution must have been far higher in countries with low safety standards and high HIV transmission rates, such as Namibia. Strangely, Pepin claims that safety in health facilities has improved so much in the ten years from 2000 to 2010 that "unsafe injections caused between 16,939 and 33,877 HIV infections" globally in 2010.

It is not very clear where Pepin got all his figures to carry out this estimate but there were an estimated 1.6m new HIV infections in sub-Saharan Africa in 2012 (compared to 2.6m in 2001). Does it seem credible that something in the region of 1.5% of all new infections globally (33,877 as a percentage of 2.3m new infections in UNAIDS' 2013 Global Report), at the most, were transmitted through unsafe injections? It sounds like Pepin was trying to find a figure that concurs with UNAIDS' Modes of Transmission Analyses, which have been claiming that the contribution of unsafe injections in African countries has been at that very low level since they started carrying out these analyses.

The Modes of Transmission model is so flawed that it overestimates heterosexual HIV transmission by several hundred percent, leaving the majority of transmissions unexplained. Therefore, their minute figure for transmission through reused syringes and other forms of unsafe healthcare could not possibly be correct, and seems to have been arrived at by overestimating heterosexual transmission and then claiming that only the remaining infections, a very small percentage, could be a result of unsafe healthcare.

Neither Pepin nor UNAIDS appear to have bothered investigating conditions in health facilities, possible outbreaks of healthcare transmitted HIV, infections among people who have never had sex, infections among people who only engage in 'safe' sex, infections in mothers who may have been infected by their infants and infections in infants whose mothers are HIV negative. If Pepin comes up with the same sort of figure as UNAIDS then his model is likely to be as flawed as theirs.

Namibia's 2006-07 DHS finds that knowledge about 'unsafe' sex is high but this has had little impact on sexual behavior, nor on HIV transmission. So, no surprise there. The report blandly states that "HIV is transmitted among adults primarily through heterosexual contact between an infected partner and a non-infected partner" (which is what all DHS reports say, along with UNAIDS and other international institutions).

Report after report comes out on 'knowledge, attitude and practices' (KAP) from high prevalence country after country, and various well funded national and international institutions never seem to wonder if reducing HIV transmission is not merely about how much people know about sex, their attitudes towards sexual transmission and their sexual practices. For how long can this go on?

There's a small amount of data in the 2006-07 DHS about whether people had medical injections and whether they remember if the person administering the injection saw the injecting equipment being taken out of a new packet, but there are no corresponding figures for HIV prevalence in relation to receipt of medical injections. It is concluded that most public and private facilities, at least 90%, practice safe injections, but that the lowest level of safe injections was found for women attending some types of private facility, at 49%; not so reassuring.

Figures for the next DHS (2013) are not yet available, but from the list of data being collected there doesn't seem to be any new attention paid to non-sexual transmission of HIV, especially through injecting equipment reuse and other forms of unsafe healthcare. If you don't investigate, you don't need to deny finding the incriminating figures. This has worked for UNAIDS, but not for Namibia, or for any other country with serious HIV epidemics.

[For more about HIV from unsafe healthcare, visit our Healthcare Risks for HIV pages.]


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