Whites Only? Investigations Reveal Hospital Transmitted Hepatitis Infections In US

The satirical site The Onion ran the headline 'Experts: Ebola Vaccine At Least 50 White People Away' at the end of July. I'm not citing this article because I think it is funny, but because it raises a shocking point very succinctly, one that must have passed through the minds of many over the past few months.

If such an outbreak were to become established in a wealthy country, mainly inhabited by white people, would it still be raging 9 months later? And what efforts would be made to establish the source of the infections?

There is probably no wealthy country precedent to compare with the sort of epidemics that are frequently found in poor countries, often without even attracting the notice of the western world (or not for very long). But a recent article published in the Mayo Clinic Proceedings outlines the kind of work that went into investigating the infection of 84 people with hepatitis C (HCV) and another 34 with bacterial infections in US hospitals over a 14 year period. In fact, the paper outlines a whole series of investigations, very impressive work, too.

Six healthcare personnel were identified as a result of these many, lengthy and thorough investigations. That's an average of almost 20 patients infected for each worker. An estimated 30,000 patients were potentially exposed to blood-borne pathogens by these six people. Twenty three different hospitals were involved, in 10 different states. (Naturally, I don't really know if the victims were all white people; the authors are far too polite to mention such detail.)

A 2009 article entitled 'Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review', by Savanna Reid, estimates that 20 million medical injections contaminated with blood from a patient with HIV are administered every year in Africa. Other research by Yves Hutin, entitled 'Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates', estimates that out of the 17 billion injections administered every year globally, 7 billion of them are unsafe.

So where are the HIV and hepatitis outbreak investigations carried out in African countries? They are not listed in PubMed, unless they are called something else, to throw investigators off the scent. Such an investigation was carried out in Pakistan in 2008, but as it confirmed the worst fears of those who believe that unsafe healthcare is a serious risk it appears to have attracted very little attention (and turned into what looks like a cover-up).

So what do we know about unsafe healthcare in African countries, in the absence of such investigations? We know that infants with HIV negative mothers were probably infected through unsafe healthcare in Mozambique, and some of the infants may have gone on to infect their mothers (though it hasn't been seen fit to explain to these mothers how their infants may have been infected, nor even the likely source of their own infection).

We know that people who have received medical injections in Kenya and several other countries are several times more likely to be HIV positive than those who have not. We know that women who have sex only with other women in Namibia and other southern African countries have been infected and that their non-sexual risks have not been investigated. We know that many people found to be infected with HIV in most African countries have said they have not had sex, or that they have not had sex with a HIV positive person, or that they have only engaged in safe sex [earlier version corrected].

In fact, there are numerous instances of HIV outbreaks in African countries, and probably other diseases, which have very likely been caused by unsafe healthcare, reused syringes and other equipment, failure to comply with infection procedures, etc. But none of them have been investigated. Instead, there are vast quantities of data shoved into mathematical 'models', showing that HIV is almost always transmitted through heterosexual behavior in African countries (this being just one example).

Completely untrue, but in accordance with the 'promiscuous African' myth, which has a long history in the medical (and eugenics) literature. The authors of such papers systematically ignore empirical data and fail to investigate outbreaks, they assume that African people themselves are either seriously mistaken about their sexual history or just tell lies, and they go unchallenged by their fellow academics and even peer reviewers, who have the luxury of remaining anonymous, but seemingly prefer to toe the party line.

No doubt these mathematical models are great examples of academic prowess and rigor, that stand up to the highest levels of scrutiny. But they are no substitute for the kind of investigations that have been carried out into what is thought to be a mere tip of the iceberg in hospital transmitted hepatitis and bacterial infections in the US. However brilliant these models are in the field of epidemiology, they are the work of people who care nothing about their fellow human beings in African countries.

Why do these highly qualified academics care so little about poor black people and, apparently, so much about people more likely to be wealthy and white? Is it academic vanity, money, some kind of animalistic competitive instinct, or a combination of these? The challenge to all these clever academics, who can publish their work in the most prestigious journals and be cited in the cream of the western media, is to go to the same lengths investigating and stopping HIV (and ebola, HCV and other diseases) in African countries as they do in parts of the US before the epidemic spreads any further.

Revised History of HIV in Kenya – Part VII – Health Facilities

Part VI explored the possibility that family planning and Sexually Transmitted Infection (STI) services may have been provided in health facilities that would later be deemed unsafe in the context of HIV, involving reuse of syringes and other equipment with inadequate or no sterilization. Many determinants have been identified for STIs throughout the twentieth century, all over the world. They include poverty, poor education, unemployment, ‘promiscuity’ (Meheus, 1974), low prevalence of contraception and others. STI prevalence tended to be higher among men than women, high in both urban and rural areas, higher among unmarried than married people (Hopcraft, 1973) and fairly evenly distributed around a country such as Kenya. In contrast, HIV is more likely to be associated with relative wealth, better education, employment, proximity to roads and other infrastructure, higher use of contraception, urban dwelling, marriage and others. More women than men are infected, associations with sexual behavior considered unsafe are often not very strong and prevalence is unevenly distributed, with a few hotspots in Kenya and many ‘coldspots’. One might logically conclude that, while HIV can be transmitted sexually, it is often transmitted in other ways, and that is why patterns of infection for HIV differ so much from patterns of infection for other STIs.

However, there are important overlaps in these patterns of STI and HIV infection. For example, HIV prevalence was found to have reached 4% among Nairobi sex workers in 1981 and increased to 61% by 1985; this was established by retrospectively testing stored blood samples (Piot P, 1987). Females infected with non-HIV STIs in the past were generally found to be engaged in sex work or had a partner who had visited a sex worker. Prevalence of STIs was often high in certain occupational groups, such as transport workers, soldiers and those employed in extractive industries. As a result, these and other groups had long been targeted by STI eradication programs; sex workers had also been targeted by various family planning initiatives. This suggests that those facing high risks for infection with STIs, or assumed to face high risks, may have had increased non-sexual risk of being infected with HIV once that virus began to spread (having established itself several decades before). Although HIV prevalence went up to 81% among sex workers in Nairobi, it peaked in 1986 and declined steadily for nearly 20 years without any reasonable explanation being found for this trajectory (Kimani J, 2008). Oddly enough, neither Piot et al nor Kimani et al consider the very strong possibility that sex workers (and members of other targeted groups) were systematically infected with HIV through unsafe healthcare until this risk was eventually recognized (or perhaps changes in practices reduced the risk of transmission without anyone noticing the impact this was having on healthcare transmission until much later?).

In the early 80s, no precautions had been taken to prevent the transmission of blood-borne viruses such as HIV in health facilities, as the virus had only just been discovered. Throughout the 80s, as it became apparent that health facility transmission was (or could become) a significant risk, certain measures were taken to improve safety. But the changes would not have been adequate to eliminate transmission altogether. In the 90s, as mentioned in Part III, access to health facilities declined, which may have inadvertently protected many people from infection; HIV incidence in the general population peaked some time in the 90s, at a time when visitor numbers to health facilities would have been falling as a result of increasing poverty, the introduction of ‘user fees’, cuts in service provision and other factors. Sex workers and others thought to be ‘promiscuous’ must have faced a very high risk of being infected with HIV in STI and family planning facilities, although the risk must have decreased considerably some time in the 80s and continued to decline, without ever being completely eliminated.

As for those not considered to be so ‘promiscuous’, they would also have faced high risks in general health facilities. Family planning and STI facilities were often integrated into general healthcare services. Women attending antenatal care (ANC) services and giving birth may have faced higher risk than others (aside from sex workers and other groups targeted by STI and family planning programs). This makes it less surprising that very high HIV rates were found in ANC clinics from the late 80s onwards. HIV prevalence is often highest among women of childbearing age. While these same women may (or may not) be more sexually active that others among whom HIV prevalence is lower, they clearly face increased non-sexual risk of infection with HIV at ANC clinics that are not particularly safe. Family planning services were promoted widely, often aggressively promoted, and not just to those thought to be ‘promiscuous’. Family planning, ANC, contraception and even general health services tend to be more accessible and more utilized in urban areas, by wealthier, better educated people (Hopcraft, 1973), the very groups found to be more likely to be infected with HIV. So people with HIV are more likely to have faced various non-sexual risks, whatever about their sexual risks. Why do UNAIDS and the HIV industry seem only to consider their sexual risks? Piot et al and Kimani et al are not exceptional in completely ignoring the possibility of massive levels of healthcare transmission of HIV; the entire industry has grown out of denying that unsafe healthcare could have played a part in transmitting a virus that is a lot less efficiently transmitted through heterosexual sex.

For a long time in Kenya (and other developing countries), family planning had been seen as a means of ‘promoting economic development’, as well as ‘improving maternal and child health’. It wasn’t just highly intrusive and aggressively promoted because it was seen as beneficial to Kenyans and other Africans, but also because it was seen as a means of reducing population growth and averting an eventual global shortage of food, water and vital resources. In the same way that preventing and treating diseases in developing countries was a way of ensuring a ready supply of cheap labor in resource rich countries, family planning was seen as a way of controlling birth rates and population increases beyond what was needed for labor. For many NGOs operating in African countries now, family planning is development; and ‘maternal and child health’ consists of, pretty much, family planning. It is seen as something of a truism that maternal and child deaths can be reduced most readily by reducing fertility rather than, say, improving conditions in hospitals and elsewhere.

A 1973 paper reveals something about conditions in STI clinics in Uganda (Arya, 1973). For a start, it is pointed out that over 90% of the population lives in rural areas. Therefore, most of the population’s health needs are catered for by rural health centers, dispensaries and other minor facilities, staffed mainly by auxiliaries, rather than by more highly trained professionals. Whether it is because STIs were common or because the colonial and post-colonial administrations were exceptionally interested in them, Arya argues that “venereal disease played an important role in the organization of the medical services in Uganda in the beginning of this century.” Mulago Hospital, started in the second decade of the 20^th century as an STI clinic, became and remains the largest referral hospital in the country. This is similar to Kenya, with specialist STI services being available in Mombasa and Nairobi for many decades. Health expenditure is low, estimated at around one dollar per year per person in the mid 70s, but basic health services were provided free of charge. Arya alludes to the lack of success of most STI programs, in both developing and rich countries, in bringing these diseases under control; he suggests that there are other diseases that may be in more urgent need of attention. Arya also notes that private practitioners provide STI services, mainly in larger towns, and that the quality of these services is unknown.

Arya published a paper in 1976 about the role of medical auxiliaries in STI control in developing countries (Arya & Bennett, 1976). In common with some other authors, Arya and colleague draw attention to the high disease burden faced by developing countries, coupled with the scarce resources, human, financial and material. These are particularly acute in rural areas, where most people live, but where well qualified professionals are reluctant to work. The authors also feel that STI services are mismanaged to the extent that they may be causing more problems than they are solving, with high prevalence resulting from “inadequate treatment, improper treatment or no treatment at all”. They mention high treatment default rates, find the contribution of private practitioners to STI control ‘questionable’ and conclude that the overall quality of services is poor. Diagnoses were unreliable (Burney, 1976), patients were receiving repeated injections of small doses of penicillin, which increased resistance, etc. Another paper notes the injection of large volumes of penicillin in some countries, which is likely to have involved the use of glass syringes and reusable needles in those days (Meheus, 1974). Contact tracing was generally beyond the capacity of STI service providers. Arya and Bennett recommend that medical auxiliaries specialize in STIs and that their training includes “knowledge of the local socio-cultural factors which largely determine traditional sexual mores” and note that STI patterns “differ from those in the western nations and may even vary from one area to another within a country”.

The papers cited above and in Part VI give a few insights into what things were like in terms of STI programs in Kenya and Uganda in the 1970s. Many of those said to be dying of ‘slim disease’ in Uganda in the early 1980s could have been infected with HIV as long as ten years before. If the rate of new infections peaked in the late 1980s, transmission would have been increasing throughout the 1970s, reaching its peak in the late 1970s. Why incidence peaked and then declined is another story. It may have had something to do with the 1978-1979 war with Tanzania (wars tend to be periods of low HIV transmission (Gisselquist, 2004)), the civil war from 1981-1986 or, much more likely, a combination of factors. Incidence began to increase a few years later in Kenya, perhaps in the mid 1970s, reaching a peak in the early 1990s, as discussed elsewhere. However, incidence started to increase earlier among certain groups, such as sex workers, transport workers and others who, significantly, had been targeted by STI eradication programs for decades. Incidence also would have peaked and begun to decline earlier in these groups.

Conditions in Kenyan health facilities in the 1970s, especially those providing STI and family planning services, were poor. If a blood-borne virus were to establish itself in one or more of these facilities, there would have been plenty of scope for it to be transmitted widely, not just among populations aggressively targeted by various health programs, but also among those requiring other health services, such as antenatal care. The risks of widespread transmission of HIV in health facilities were not recognized for a number of years and many more years had passed before any of these risks were addressed (some have yet to be addressed). But western HIV awareness campaigns were hijacked long ago by various parties who wished to present the virus as one transmitted almost entirely through ‘promiscuity’, and who wished to deny the possibility of transmission in health facilities. Because most of those infected in African countries were heterosexual, a different story about transmission needed to be created. Unfortunately, the same campaigns and strategies were exported from wealthy countries, where transmission was almost entirely a result of male to male sex or intravenous drug use. These campaigns were supremely unsuccessful in Kenya, but this was blamed on the failure of individuals to change their sexual behavior, rather than on any non-sexual mode of transmission.

If HIV transmission in health facilities and through other non-sexual modes continues, the virus will not be eradicated. More poignantly, if health facility transmission had been addressed in the 1980s, when it was realized that this was a very efficient mode of transmission, the virus would never have infected so many people. Some of the worst epidemics in the world only got going in the late 1980s or early 1990s, such as Zimbabwe, Botswana, South Africa, Swaziland, Mozambique and others. Many of the biggest players (bureaucrats, politicians, publicists, academics, industrialists, etc) currently driving the HIV industry have been in the business since the 1980s. Must Kenyans and other Africans wait till these ‘experts’ are gradually replaced by more enlightened personages? It is to be hoped that new generations of practitioners are not obliged to choose between adopting the deeply engrained institutional prejudices of their profession, or accepting the status of ‘dissident’ or ‘denialist’, unable to publish, teach or even present their views to the industry.

REFERENCES:

Arya, O. (1973). Changing patterns in the organization of the venereal diseases and treponematoses service in Uganda. Brit. J. vener. Dis, 134-138.

Arya, O., & Bennett, F. (1976). Role of the medical auxiliary in the control of sexually transmitted disease in a developing country. Brit. J. vener. Dis., 116-121.

Burney, P. (1976). Some aspects of sexually transmitted disease in Swaziland. Brit. J. vener. Dis., 412-414.

Gisselquist, D. (2004). Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa. SAHARA J., 114-27.

Hopcraft, M. V. (1973). Genital infections in developing countries: experience in a family planning clinic. Bulletin of the World Health Organization, 581-586.

Kimani J, K. R.-A. (2008). Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence. AIDS, 131-7.

Meheus, A. D. (1974). Prevalence of gonorrhoea in prostitutes in a Central African town. Brit. J. vener. Dis., 50-52.

Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.

Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.

Revised History of HIV in Kenya - Part VI - Family Planning & STIs

Could sexually transmitted infection (STI) programs that started many decades before have been involved in the inadvertent transmission of HIV as early as the 1970s in Kenya? Those targeted by STI programs were women and men who attended STI clinics, or presented with STIs or STI symptoms. A short paper by Peter Piot is often cited to show that HIV prevalence went from 4% in 1981 to 61% in 1985 (Piot P, 1987), and that therefore sex workers (and their clients) must have been incredibly sexually active, and also far more efficient at transmitting the virus to men through heterosexual sex than one might expect (given what has been shown about transmission rates since then). But the possibility that these sex workers and their clients were infected through unsafe healthcare practices in STI and other clinics has never been ruled out.

Jacques Pepin in The Origins of AIDS argues that early STI programs were almost definitely involved in spreading HIV (Pepin, 2011) in the Democratic Republic of Congo. But he uses Piot's paper to argue that sexual behavior took over from unsafe healthcare at some time; why this happened, or when, is not very clear. However, the papers below suggest that the very people among whom HIV prevalence was found to be high would also have been frequent clients in STI clinics. Conditions in health facilities probably improved during the 80s and 90s, which would have accounted for the rate of new HIV infections peaking in the early 90s and subsequently declining. But given that healthcare is not particularly safe in Kenya now, we don't know if HIV is still transmitted through unsafe healthcare, albeit at a far lower rate.

Could invasive family planning methods such as intrauterine devices (IUD), inserted in insanitary health facilities, have been involved in the transmission of HIV, perhaps also as early on as the 1970s? Family planning was most accessible and most availed of in urban areas, and the users were more likely to be better educated, wealthier and formally employed (these are still true of family planning users). Some of the earliest institutions to work with HIV in African countries were those involved in family planning. They were already well established in many countries and persuading people to have smaller families, through any means possible, was what they knew best. That’s not to say they were particularly successful, but they certainly received the lion’s share of funding at one time, until the HIV industry became the top heavy, cash rich bureaucracy that it is today, where any big NGO that toes the party line will get ample funding. Perhaps some of the industry’s obsession with sexual transmission, to the exclusion of most forms of non-sexually transmitted HIV, relates to their origins, which can include puritanical religious beliefs, Malthusianism and neo-eugenicism, to name but a few.

Kenya is said to have been “the first country in Africa south of the Sahara to adopt family planning as a national policy” (Fendall & Gill, 1970), with the earliest family planning efforts starting in Mombasa in 1952. At first, it was decided that Kenya’s population growth was not particularly worrying and the policy started off fairly moderate. There were 25 clinics by 1965 in a country with a population of about 11 million (as of 1969). But in the early and late 60s, censuses showed that population growth was about 3%, far exceeding death rates. An average of 7 children were born to women reaching 50 years of age and average life expectancy was 40-45 years. Those engaged in family planning resolved to reduce fertility by 50%, with intrauterine devices (IUD) being seen as the best contraceptive method for achieving this. Family planning was to be integrated into public health services and it would be free and voluntary (although costs involved in attending the clinic were not covered, which may account for the relative popularity of longer acting methods, which didn’t involve repeat costs).

The number of clinics had reached 160 by 1970, with the biggest being set up in urban areas, along with some of the more heavily populated non-urban areas. Smaller units and mobile teams operated in less accessible areas (although some of the higher populated areas are not urban, such as in the Western and Nyanza provinces, where population is also dense). The Family Planning Association of Kenya claimed to have 17,000 clients in 1965, of which 70% were urban and 30% were rural. It is possible that independence interrupted progress that had been made in the previous two decades. With a growing population and limited revenue, the government needed to provide the free health service they had promised. But the first 20 years or so of family planning may have set some of the patterns that continued for the two or three decades following, and perhaps still exist. Contraception tends to be far more common in urban areas, among better educated, wealthier, urban dwelling people.

British colonial concern about sexually transmitted infections (STI) dates back at least to the 1920s and by the 1970s resistance to antibiotics and penicillin for the treatment of gonorrhea was already common in rural and urban areas. This may suggest that people with STIs had been able to access health services for some time, but that those services were not able to eradicate the most common infections. It is likely that many people did not return for some lengthier forms of treatment, which could involve a lot of discomfort, as well as considerable expense from travel and other costs. A paper from 1971 mentions ‘selected social groups’ being investigated in the past for resistance, including people in capital cities, harbor areas, ‘special elite groups’ (whoever they may be), foreign soldiers and ‘hostesses catering for them’ (Verhagen, 1971). (These are some of the groups among whom HIV was later found to be highest.) But the authors suggest that these groups are not representative of the population as a whole and exclude the majority of gonorrhea patients. It is hinted that the reason these groups are targeted in Kenya is that they may have been the groups most likely to be infected in wealthier countries, such as the UK, but that the analogy didn’t quite work. It is noted that Mombasa and Nairobi have ‘special VD clinics’, although the one in Mombasa only treats sex workers, whereas the one in Nairobi also treats the general population.

A paper published the following year aims to establish the determinants of gonorrhea in Kenya (it is notable that, out of the few papers available in full, many are about gonorrhea, fewer are about other STIs; also, most studies tended to be carried out in a handful of countries, with Kenya being one of the handful). It uses data from monthly checkups for sex workers at the Mombasa and Nairobi clinics mentioned above (Verhagen & Gemert, 1972). One of the authors, Verhagen (and perhaps some of his contemporaries), is interesting for being a lot less judgmental than one might expect, especially given the deep racism later found in institutions working with HIV. Some questions about sexual behavior were deemed ‘too intrusive’ to ask people in their control group. UNAIDS’ criteria for ‘sex work’ is often inclusive enough to be applicable to almost every sexually active person in the country, and even many people who are not sexually active. The authors also draw attention to the fact that attendance for all medical services increased rapidly when treatment became free in 1965.

Gonorrhea tends to infect people who may be more ‘promiscuous’, such as sex workers and their clients. Simple supply and demand would suggest that sex workers must be fairly small in number, whereas clients need to be plentiful. As sex workers are usually female and clients usually male, gonorrhea may therefore be expected to infect more males than females. Verhagen and Gemert find that the male:female ratio is 2:1 in 1964, rising to 6:1 in 1970 and 8:1 the following year. They note that the ratio for syphilis is usually around 2:1. The authors are not able to estimate incidence of gonorrhea but they conclude that Kenya has relatively low incidence, as the disease globally is said to be currently the most common notifiable disease after measles.

Despite earlier findings that patients with STIs are “found among distinct social groups such as the lower social strata, members of migratory or itinerant professions, and other groups characterized by social instability”, this paper concludes that there is “a striking similarity between patients and controls.” Many of the women were single and unemployed (although many were sex workers) and many people who were married and had STIs spent long periods away from their partner, this being more a feature of urban, rather than rural living. Men with STIs usually attributed their infection to someone other than their wife, while women with STIs were often less well educated, as well as being single and not conventionally employed, which strongly suggests that they were very poor. Even among those deemed to be sex workers, it was ‘the smarter and more expensive girls’ who received the monthly checkup, so they may have been less likely to be infected with gonorrhea and other STIs than other clinic patients.

UNAIDS and the HIV industry have a fondness for identifying (and thereby stigmatizing) multitudes of HIV ‘risk groups’, at least one of which almost everyone falls into at some time. In contrast, Verhagen and Gemert assume “that encounters in bars, brothels, dance-halls, and in the street (termed the BBDS category) were the more casual and usually reflected prostitution and promiscuity”. This must have made it a lot easier to target people at risk of being infected with an STI, or of transmitting it to others. The difference in approach may explain the lack of successful HIV prevention interventions, especially before the widespread availability of antiretroviral drugs. Half of the male patients are said to have been infected by someone they met in a brothel, a bar or a dance hall, with brothels only accounting for 10% of all gonococcal infections; the other half met the sexual partner on the street or near where the partner lived. Although the fairly small number of ‘promiscuous’ females infect a larger number of males, fewer of those males go on to infect another partner, such as their wife. The authors neither conclude that all (or most) men are promiscuous, nor that all (or most) females are. The phenomenon of large numbers of single men and married men who live away from their partner, which was very often the case in cities, and a small group of women to cater for their sexual needs, is identified as a major driver of high rates of STI transmission (as it was later said to be in relation to HIV). Even the ‘breakdown in traditional ethics’ said to result from migration and urbanization, frequently remarked on later, had been noted by authors several decades before.

Generally, far fewer women than men were infected with gonorrhea and other STIs. Quite a number of these women were said to be ‘non-promiscuous’, having been infected by a promiscuous partner. Sex workers are often badly educated, unemployed migrants whose marriage may have broken down and who come from a particular tribe associated with these and other factors. Comparing their study participants with a control group, it is found that many of the males are young, badly educated, unemployed, living in overcrowded conditions and are recent arrivals in the study area. The authors warn that “The self-image of an indiscriminately promiscuous community (which in view of our findings in regard to the regularly married is wrong), ostracism against prostitutes and emotional outbursts blaming a particular sex or group of persons are of no help.” That warning, along with others, was to fall on deaf ears. “No distinct high risk groups were found” in the course of this study.

The above papers are of interest to a history of HIV in Kenya because many sexually transmitted infections are a lot less likely to be transmitted through any other route, such as unsafe healthcare. In contrast, HIV is relatively difficult to transmit sexually and easy to transmit through unsafe healthcare, unsafe cosmetic practices and various skin piercing traditional practices. As I have mentioned in earlier posts, HIV is often correlated with higher wealth, better education, employment (as opposed to unemployment) and urban residence, and prevalence is generally higher among women. Many of the factors involved in the transmission of HIV seem to the opposite of those involved in transmission of gonorrhea and some other STIs.

What about factors for STIs and factors for HIV that seem to overlap, such as involvement with sex work, migration, mobility and the like? The above papers, along with others from the decades preceding the discovery of HIV, suggest that sex workers, immigrants, transport workers, migrant workers and those engaged in certain occupations had long been targeted by STI programs. These programs were most prominent in areas that attracted migrants, cities and areas with high labor needs. Could some of these programs have been inadvertently involved in the transmission of HIV to the groups that were later found to have been infected, as if en masse? What about family planning? Could the use of IUDs have infected many women? There is certainly plenty of evidence that conditions in health facilities were poor, that health facilities were oversubscribed, underfunded, understaffed and not the safest place to go for preventative or curative treatment. Even the connections between population growth and density alluded to by some HIV commentators may relate to the relative success of family planning and STI eradication programs in urban, as opposed to rural areas. Higher levels of education and wealth are generally associated with both family planning and health seeking behavior in general; but while these factors are associated with higher HIV prevalence, the opposite is true of STIs.

The massive increase in HIV prevalence among sex workers found in Nairobi, from 4% to 61% between 1981 and 1985, may have been a result of unsafe healthcare, especially in facilities providing STI and family planning services. Historical and contemporary studies show that HIV is only sometimes transmitted sexually; patterns of infection only overlap to a limited extent with those for STIs. The relative contribution of sexual and non-sexual transmission to Kenya's epidemic remains unknown; until it is known, epidemics like that in Kenya will continue indefinitely. Yet the HIV industry is still happy to accuse those infected of being highly promiscuous, and of being indifferent about transmitting the virus to their partners and infants.

[The list of publications below is short and I will comment on other publications in the next part.]

REFERENCES:

Fendall, N., & Gill, J. (1970). Establishing Family Planning Services in Kenya. Public Health Reports, 131-139.

Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.

Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.

Verhagen, A. (1971). Diminished Antibiotic Sensitivity of Neisseria gonorrhoeae in Urban and Rural Areas in Kenya. Bulletin of the World Health Organization, 707-717.

Verhagen, A., & Gemert, W. (1972). Social and epidemiological determinants of gonorrhoea in an East African country. British Journal of Venereal Diseases, 277-286.