Sunday, September 7, 2014
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
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
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 20th 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.
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.