Do Sick People Attend Health Facilities or Do Health Facilities Spread Disease?

A systematic review by Didier Pittet and others finds that rates of health care associated infections (HAI) are far higher in developing countries than they are in Europe and the USA. This is no great surprise, but such findings by prominent academics in a prestigious journal may make UNAIDS and others in the AIDS industry sit up and take notice for a change.

The HAI prevalence rate in developing countries was found to be 15.5 per 100 patients, more than double the rate in Europe and nearly four times the rate in the USA. In some hospital areas, such as intensive care, the rates were far higher. The report also finds that surveillance is rare and HAI rates are seriously underestimated. Developing countries simply don't have the resources to carry out such work.

However, an example of a cheap and simple surveillance exercise was carried out in Northern Tanzania in 2003. This exercise found that HAI incidence was 14.8% on the day they collected data. It also found that rates were far higher in some hospital locations, such as intensive care, surgical and even general medical wards.

The main concern of this blog is the rate of non-sexually transmitted HIV, especially the rate of blood-borne infections, that may be related to unsafe health care. According to SafePoint Trust, as many as 260,000 HIV infections every year result from unsafe injections (which is only one area of unsafe health care practice).

To put the WHO estimated rate of nosocomial (medical procedure related) HIV infection of over 14% in perspective, it is far higher than the rate of infection found among sex workers, sex worker clients, sex worker client partners and even men having sex with men. People attending health facilities are one of the highest risk groups in developing countries.

In addition, an estimated 1 million hepatitis C (over 30% of all cases) and 21 million hepatitis B infections (40% of all cases) result from unsafe injections. Syringes, designed to be used only once, are reused, often without adequate sterilization. More people are killed every year by unsafe injections than by malaria.

It's not just syringes that are reused without sterilization. Catheters, ventilators, dental and other invasive equipment can all be involved in transmitting infections of various kinds.

A particular worry is HAI rates among infants and young children, which can be many times higher than those among adults. But whenever the issue of nosocomial HIV infection in children is raised, 'professional' health care commentators get in a flap about putting people in developing countries off using health facilities (this is just one small example).

However, if these facilities are as dangerous as the above report suggests, people are entitled to know the risks and take steps to avoid them. More importantly, governments in developing countries need to take action. They receive billions of dollars in donor funding to treat people for HIV. A small amount of this would ensure than hundreds of thousands of infections are avoided in the first place.

High rates of HIV transmission tend to be found in areas with health facilities. Low rates of HIV transmission tend to be found in areas where health facilities are inaccessible or non-existant. These tendencies are established by population based surveys.

The Lancet report identifies the potential determinants of HAIs as: "inadequate environmental hygienic conditions; poor infrastructure; insufficient equipment; understaffing; overcrowding; paucity of knowledge and application of basic infection-control measures; prolonged and inappropriate use of invasive devices and antibiotics; and scarcity of local and national guidelines and policies." It also notes reuse of scarce resources, such as needles and gloves.

The question is, are people flocking to health facilities because they are infected with HIV or are health facilities playing a part in transmitting HIV, and if so, to what extent? This question needs to be answered before another year passes and another 260,000 avoidable HIV infections occur.

Are We About to Take the Biggest Step Yet in Reducing HIV Transmission?

Recently, I blogged about WHO's estimates for the number of people infected every year with HIV through unsafe injections and wondered why the number, 23,000, was so low. It was an error in the original reporting. In fact the number is 260,000 HIV infections. In addition, unsafe injections account for millions of transmissions of hepatitis B and C and a host of other diseases.

To put this in perspective, just under 10% of HIV in Uganda is transmitted via sex workers, their clients and their clients' partners, all together. The figure for Kenya is about 15%. But the contribution of unsafe injections is estimated at about 14%, and it could be a lot higher in some places.

The majority of HIV positive people in high prevalence countries did not engage in 'unsafe' sex, according to Modes of Transmission Surveys. But you'd never think that when you read articles about sexual behavior and commercial sex work. The percentage actually attributed to sex workers is less than 2%. It's the clients and partners of clients who make up the bulk of that 10% figure.

Despite sex playing a far smaller role in the AIDS pandemic than we are led to believe by most media and academic writings, the evidence that something else is playing a big part is all around. In South Africa, farm workers in two provinces have some of the highest rates ever found anywhere, almost 40%. Compare this to HIV prevalence among sex workers in India, which stands at about 7%. That's about the same as national prevalence in Kenya, Tanzania and Uganda. Are we supposed to conclude that some Africans engage in far more unsafe sex than Indian sex workers?

The Institute of Migration study, apparently, "could not pin-point a single factor causing this high rate of HIV infection on these farms but points instead to a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of Sexually Transmitted Infections (STIs) and/or TB and high levels of sexual violence". But these factors are present in many places in the world, in developing and developed countries, without giving rise to such astonishing HIV rates.

Dr Eric Ventura says that more research is clearly needed. But perhaps some different research is needed and even some investigation of the results of some already completed research. Not that there isn't plenty of research into non-sexual transmission, but UNAIDS and many others in the HIV industry choose to ignore it. Perhaps now that WHO have seen the light, UNAIDS will follow. But Ventura suggests, among other things, increasing farm worker acces to healthcare.

Perhaps access to healthcare is the biggest problem in South Africa and some of the surrounding high prevalence countries. Most of the very high HIV prevalence African countries have better access to healthcare than some of the medium prevalence countries, such as Kenya, Tanzania and Uganda. But what quality of healthcare? Increasing access to healthcare will be counterproductive if poor healthcare is contributing more to the pandemic than commercial sex, which has been such a popular punchbag up to now.

Very slowly, the issue of injection safety and other forms of non-sexual transmission of HIV is being raised and even being picked up by the media. The above figures about unsafe injections were supplied by Safepoint Tanzania, who have been trying to get this vital topic on the agenda. But when it comes to media attention, or even that of the HIV industry, sex always trumps boring old healthcare.

With all the interest in criminal HIV transmission (through 'unsafe' sex, of course), I wonder if we will ever look back on the days when UNAIDS and others tasked with reducing HIV transmission consistently refused to accept that a very significant proportion was coming from unsafe injections and ask ourselves how they could get away with this? Because what they are getting away with now constitutes professional negligence that far exceeds that of those who continued to use blood products contaminated with HIV long after they knew the risks.

As another World AIDS Day looms and the 'experts' drone on about what a brilliant job they have been doing, it's time to take what will be the biggest single step ever towards reducing HIV transmission in African countries. That is to recognize that HIV is not just about sex, unsafe or otherwise, and by acting to eliminate the most avoidable and preventable factors in the spread of the virus: unsafe injections and other healthcare procedures.

UN's IRIN Fluffs Issue of HIV Transmission in Medical Facilities

The issue of non-sexually transmitted HIV is rarely discussed in medical or official literature, or anywhere else for that matter. But there is a recent article on IRIN's PlusNews about the risk of accidental HIV transmission to health workers in Kenya. The article notes the need to provide health workers with proper safety equipment and education.

These are vital, not just to protect health workers, but to protect patients. If health workers don't have adequate equipment or if they don't adhere to strict hygiene practices, their patients face far higher risks than the health workers.

Unfortunately, the article botches the message in the second paragraph. They say that 2.5% of new HIV infections every year occur in health facilities. But this does not mean that 2.5% of the country's HIV infections occur among health workers. It means that the figure some epidemiologists have modeled, somehow, suggest that as few as 2.5% of HIV infections are caused by medical procedures, some of those being among health workers. There is no attempt to work out how many health workers are infected. And it's not as if such occurrences are properly recorded, that would be far too sensible.

In fact, the figure of 2.5% is just not credible. The WHO accepts that 70% of injections in developing countries are unnecessary and that almost 20% in some countries are unsafe. Why should Kenya, with it's deplorable health facilities, only have a 2.5% rate of medical transmission? The article even claims that "most government facilities adhere to safety guidelines" and blame "private practitioners in poor areas" for medical transmission.

Kenya's Service Provision Assessment suggests, on the other hand, that safety guidelines are not common. The assessment doesn't even question whether the guidelines are adhered to. They do assess how many facilities have the requisite equipment; not many.

The article seems to suggest that those living in rural areas are more at risk of unsafe health care. People in rural areas may face different risks that urban dwellers, possibly even high risks. But HIV rates are far higher in urban areas. People in rural areas are, however, far less likely to receive any kind of modern medical services. It's striking how the most isolated places of all have very few cases of HIV.

The article says that "patients themselves may not be knowledgeable enough to question unsafe practices", so it isn't a complete waste of space. Patients, Kenyans and other Africans, are quite unaware of the dangers they face, mainly because articles like this one seriously underestimate the level of risk.

A 'self-employed' health worker admits that they don't always have safety equipment, though they frequently give injections. Health workers are right to be concerned for their own health. But the government and those involved in improving medical safety should pay a lot more attention to patients. Health workers may receive the odd scratch or jab from a needle but patients receive much of whatever the equipment is contaminated with, under their skin, into their muscles or even into their veins.

Given the lack of training and equipment among health workers, any initiative to increase training and supplies should be commended. But this is not going to happen overnight, if it even happens at all. Everybody visiting a health facility should know about the risks they and their family members face so that they can take steps to protect themselves against nosocomial transmission of HIV, hepatitis and other blood borne diseases.

Yet again, an article touching on the issues of medical safety and the risk of HIV transmission through unsafe medical procedures completely fluffs the issue. Visiting medical facilities in African countries is extremely hazardous. An indication of how hazardous it is can be gleaned from the advice given by UNAIDS to UN employees:

"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. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."

This is great advice for UN employees (IRIN is part of the UN), even though they have access to UN approved facilities and the option to wait till they are in a country with better medical facilities. However, UNAIDS doesn't feel it is necessary to give the same advice to Africans. They, it appears, only face a very small risk of infection.

There's Plenty of Evidence, Now We Need Investigations

Having looked at some of the figures for HIV prevalence in Kenya collected in 2007 and published earlier this year, I was not expecting another set of figures to come out so soon. But the 2008-09 Demographic and Health Survey (DHS) was released recently, so it's worth looking at some of these figures.

Since the 2003 DHS, prevalence has fallen slightly, from 6.7% to 6.3%. The major falls were in Nairobi and Coast provinces, though prevalence also fell in five other provinces. The only province that saw an increase was Western province, which went from 4.9% to 6.6%. This is good news, given that the 2008 Kenya Aids Indicator Survey (figures collected in 2007) found that prevalence had increased overall.

HIV prevalence in Kenya has always been higher in urban than in rural areas. However, the trend is for the share of infections in rural areas to increase. And as the vast majority of Kenyans live in rural areas, the number of people living with HIV in rural areas has long been higher than the number in urban areas.

The ratio of female to male infections overall has remained steady, at about 2 females for every one male. But in most provinces, this ratio has altered considerably. In Eastern province, for example, the ratio went from 4 women to every one man in 2003 to 4 women to every 3 men in 2008.

Despite the epidemic affecting women far more than men, there is still a lot of emphasis on the presumed effectiveness of male circumcision. This is said to give men some protection from HIV, though little or none to women. However, the mass male circumcision campaign in Kenya concentrates on only one of the three tribes in only one of the eight provinces, the Luo tribe of Nyanza. This makes the finding that "Luo men who are circumcised have roughly the same HIV prevalence as Luo men who are uncircumcised (16 percent compared with 17 percent)" rather shocking.

A campaign by CDC (US Center for Disease Control) aims to circumcise in excess of one million Luo men in the next year or so. I wonder how much they have told the men about this sort of finding.

The assumption that HIV is almost entirely transmitted sexually, especially by 'high risk' sex, is as pervasive as ever. That assumption is challenged by some of the findings, without being modified in any noticeable way. For example, in Table 14.7, relating to HIV prevalence by sexual behaviour, females reporting no sexual intercourse in the last 12 months have higher prevalence than those reporting 'higher risk' intercourse.

HIV prevalence was twice as high in females who reported sometimes using a condom (16%) than in those who reported never using a condom (7.8%). It's hard to know what is going on here but one thing is sure: if condoms were so ineffective in Western countries, there would be a thorough investigation. How can people be more likely to be infected if they use condoms? The Catholic and other Christian Churches should be happy as they have long preached against the effectiveness and morality of condoms. But if there is a question mark over both circumcision and condom use, how does Kenya now propose to reduce HIV infections?

It is hard to maintain the assumption that HIV is mainly transmitted sexually in Kenya without at the same time assuming that women must be far more promiscuous than men. There is no independent evidence showing that African women are more promiscuous than African men or that Africans are more promiscuous than non-Africans, for that matter. But over and over again in these figures women and girls, from a young age, are infected in much higher numbers than men. Assuming that these women are infected by men, where are all these men? Unless there is a small number of men who do most of the infecting and most of these women are having sex with them at some time, the HIV epidemic in Kenya is hard to understand.

There are figures that may support the contention that HIV is mainly transmitted sexually. For example, in both men and women, those with a history of having a sexually transmitted infection (STI), or symptoms of one, are twice as likely to be HIV positive as those who have not. But this could also suggest that people attending STI clinics are being infected with HIV through unsafe medical practices.

Indeed, the possibility of unsafe injections as a mode of HIV transmission is mentioned twice in this 455 page report. The fact that some people who are HIV positive reported never having had sex raises this possibility. But it is tempered by the possibility that sexual experience can be underreported, which it can. It can also be overreported. But will this lead to an investigation into why some people who say they have never had sex turn out to be HIV positive? I can't imagine such a finding not being investigated in a Western country.

If there are people who have been infected non-sexually in Kenya, and it's highly unlikely that there are none, this needs to be investigated. Because people who are sexually active can also be infected non-sexually. There has not been a proper investigation in Kenya into what proportion of HIV is transmitted non-sexually. The assumption that HIV is predominantly transmitted sexually has shaped HIV intervention policy and this policy appears to be failing. HIV prevalence has stayed at about the same level ever since the high death rates of the early 2000s have gone down.

Another area for enquiry is the large number of men who are infected whose partners are not and the large number of women who are infected whose partners are not. We can't just assume that they have all been infected because they are promiscuous, especially when they say they are not. Even where both male and female partners are infected it can turn out that they didn't infect each other. People are being infected with HIV and they have no idea why. The authors of the DHS have no idea why, either. HIV transmission will not be eliminated or even reduced substantially until we understand exactly how people are being infected.

There is no shortage of evidence showing that the behavioural paradigm is wrong; we cannot explain high rates of HIV prevalence in Kenya and other African countries on the basis of higher rates of 'risky' sexual behaviour. Research has shown that, on the contrary, high rates of the sort of sexual behaviour thought to be most risky are more likely to be found in Western countries, where HIV prevalence is low. If HIV is not only transmitted sexually, we need to establish how else it is being transmitted, to what extent and how best to eliminate these modes of transmission.

Give those Women a Pat on the Head

Those in the Aids industry often talk about gender and empowerment in relation to reducing HIV transmission. But what do they mean? Do they mean that women would be able to protect themselves from HIV if only their rights were recognised, such as the right to decide when, where, with whom and under which circumstances to have sex? Well, gender inequality is repulsive in many ways and it has numerous negative consequences. Gender equality is a human right and we should strive for full gender equality everywhere and remove barriers to equality.

But in developing countries like Kenya, people face all sorts of risks that make them vulnerable to diseases, not just HIV. And the risk of sexually transmitted HIV is higher where women don't have rights to negotiate or determine their sexual or reproductive life. The Aids industry seems anxious to inform women about these rights but they don't seem to regard women's rights to safe healthcare as being important, or as having any relevance to their sexual or reproductive life. These issues only merit brief mention every now and again. I read or scan through hundreds of articles every week and rarely come across one that even mentions the non-sexual risks of HIV.

To repeat myself, gender inequality is repulsive and such inequalities are probably involved in transmission of all sorts of disease and exposure to many risk factors, such as lack of access to clean water and sanitation, adequate housing and a clean environment. But gender inequality itself does not transmit HIV. HIV is a virus transmitted from person to person, through sexual intercourse, by HIV mothers giving birth or breastfeeding or through unsafe medical or cosmetic procedures.

It may sound like hair splitting, but people will continue to have sex (I presume) even if gender inequalities are reduced, they will continue to have children and they will continue to avail of medical and cosmetic procedures. Ensuring that women have the right to choose the circumstances under which they do these things is all very well, but what sort of choices are women going to make when, firstly, they don't know anything about unsafe medical and cosmetic practices and secondly, they have no influence on how those practices are carried out or how to make them less risky?

The truth is that the Aids industry is very much in the dark about how HIV is transmitted in most countries. They know that medical and cosmetic transmission occurs but they have not investigated instances of these kinds of transmission. They have chosen to concentrate on sexual risk to the exclusion of all other risks. They have made a choice about the health and welfare of people, especially women (who are exposed to far more healthcare and cosmetic risks than men), that disempowers women in developing countries. By deciding what risks women need to avoid and ignoring others, the Aids industry is doing the opposite to what it says: it is beating the empowerment drum while silently spreading disempowerment.

Incidentally, the HIV 'gender imbalance' in Kenya is quite curious in many ways. North Eastern province has the worst Gender Development Index (GDI) but also the lowest HIV prevalence. This province also has the highest percentage of girls married by the age of 18. The province with the lowest percentage of girls married by age 18 and one of the best GDI figures, Nairobi, has the second highest HIV prevalence.

Looking at it another way, in Central and Eastern provinces there are four HIV positive women for every one HIV positive man. These two provinces have little in common, with Central having the best set of development indicators and Eastern having one of the worst. Central province has only half the HIV prevalence rate of the country as a whole but Eastern has only a third, in other words, very low HIV prevalence. According to the received Aids industry view, somehow, a small group of men manage to infect a very large group of women. What, exactly, is the Aids industry saying about the sexual behaviour of people in these provinces?

Compared to that, there are only two HIV positive women for every one HIV positive man in North Eastern and Rift Valley provinces. As you move to the provinces with 'more equal' HIV epidemics, where there are only 1.5 HIV positive women for every HIV positive man, you find that these three provinces all have relatively good GDI scores but they account for half of the HIV positive people in Kenya. The Aids industry may interpret this as showing that sexual behaviour in these provinces is not as risky as that in some other provinces. Yet this lower level of risk seems to give rise to much higher rates of HIV transmission.

The oddest ratio of all is found in Coast province, where there are only 1.3 HIV positive women for every one HIV positive man. This looks more like a truly sexually transmitted disease, where male and female prevalences are similar enough. But this is also the province where there is likely to be the highest rates of intravenous drug use (mostly men) and sex tourism (which doesn’t seem to result in large numbers of HIV positive tourists). Even men having sex with men is said to be high here but I don't think that is borne out by the evidence. But is this infection ratio really a reflection of sexual practices here being quite different from those in other provinces? It would be difficult to say without investigating, not just sexual practices, but also any other ways in which HIV could be transmitted.

HIV transmission patterns are very complex and vary a lot, even within a country like Kenya. Gender is, of course, relevant. But perhaps it's not relevant for the reasons the Aids industry wants us to believe. There is little to be gained by patronising campaigns that tell women how hard their lives are but that also ignore the very risks that could most easily be avoided. Gender inequalities don’t just relate to people’s sexual behaviour, they relate to people’s access to healthcare, education and other social goods. Gender inequalities also relate to the sorts of information that people have access to. The Aids industry currently ensures that women don’t have access to adequate information that would allow them to protect themselves and their children from HIV and other diseases.

Women can be empowered and stigma can be reduced at the same time by accepting that HIV is not just transmitted sexually. To work out what proportion of HIV is transmitted sexually and non-sexually, the Aids industry needs to stop obsessing with people's sex lives and further humiliating them. The industry needs to investigate the numerous women who are HIV positive when their partners are HIV negative and the numerous children who are HIV positive but who were probably not infected by their mothers. Simply telling people that being HIV positive is not their fault while making it clear that you think it probably is their fault is not going to help people to avoid HIV risks or to reduce stigma.

Bandying about words like 'gender', 'empowerment' and 'stigma' is not going to reduce HIV transmission as long as non-sexual HIV transmission is left out of the picture. At present, the strategy of the Aids industry simply disempowers people and increases stigma. Don't just pat people on the head and tell them it's not their fault, show them how HIV is being transmitted and how they can protect themselves and others.

HIV Risk From Lies and Half Truths

In the run up to the World Cup in South Africa, the excuse for talking exclusively about sexual behaviour and HIV risk and ignoring any other risks, such as the risks of medical transmission, seems to be that sexual transmission is the most common form of transmission in African countries.

The view that sexual transmission is so common that non-sexual transmission is almost negligible is debatable and the official figures are based on guesswork rather than proper research. But even if the figures were correct, it would be stupid to ignore non-sexual risks just because sexual transmission is more common.

Driver error may be a common cause of road traffic accidents but I wouldn't want to ignore the fact that my breaks are worn out just because it is a less frequent cause of accidents.

We know that the UN worries about medically transmitted HIV enough to warn its own employees about it:

"Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. 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. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."

So why not warn soccer fans and other visitors to South Africa and other African countries? More importantly, why not warn all Africans, most of whom have no option but to use their medical facilities, no matter how inadequate they are?

Sure, international health institutions want people to trust their health facilities enough to get medical treatment when they need it, to get tested for things like HIV and to take the advice of health professionals. But is that a reason to deceive the public?

The public might be afraid that official sources are lying to them or that they are keeping something back. But official sources are lying to them and keeping something back. All over Africa, there have been clear outbreaks of medically transmitted HIV. These have been covered up or just ignored and no investigations have been carried out.

Even if only a handful of HIV infections were caused by medical transmission, people should be made aware that the possibility exists. They should be in a position to protect themselves, to insist on sterilized equipment and other safe practices. If they don't even know that unsafe medical procedures occur, they will not know that they need to protect themselves.

But there is little question about whether medical transmission of HIV is common in African countries. Medical facilities have long been underfunded, understaffed and otherwise inadequate. It would be more surprising if very few transmissions of HIV occurred than if a sizeable number occurred. The only question is about how common medical transmission is compared to sexual transmission.

In the long run, people will have more confidence in public health information and in public health facilities if they are told the truth now. Those trusted to provide people with the information they need to stay healthy are not presently entitled to that trust. Maybe people will question the safety of health facilities once they realise that things have been kept from them. But as things stand, they are right to ask questions.

If it is risky for UN employees to trust medical facilities that are not approved by the UN, it is also risky for soccer fans. And if it's risky for visitors to Africa to mistrust medical facilities, it is also risky for Africans. No amount of abstinence, faithfulness to one partner or condom use will protect people from medically transmitted HIV. HIV can be, and often is, transmitted by medical and dental treatment and by cosmetic treatment such as tattooing, piercing and hairdressing, in African countries. It is not just transmitted by 'unsafe' sex.

Condoms Won't Protect Fans Against Non-Sexual HIV Risk

Since writing about HIV and the World Cup in the last few days, I have looked for news outlets and the like for coverage of non-sexual HIV risks that people visiting or living in South Africa face. I found nothing. A couple of sites mention needle sharing as a potential risk but the tone of the warning suggests that it is aimed at intravenous drug users. There is no mention of the risks of visiting a dentist, a doctor, a nurse, a surgeon, a tattoo artist, a hairdresser or any other non-sexual risks. Can journalists and others trying to squeeze all that they can out of the World Cup not find space for a brief mention of these issues?

The remarkable thing about medical transmission of HIV in African countries is not that it doesn't happen. It's that no investigations have been carried out when medical transmission has clearly occurred or where it may have occurred. Infants, children and even adults who have had no sexual exposure are HIV positive, yet there have been no calls by international health institutions, African governments or HIV donors for investigations. In most African countries, the number of women infected far exceeds the number of men infected. And though women's groups fall over themselves to get their issues heard, they don't seem to be outraged that women seem to comprise the largest number of victims of medically transmitted HIV.

Compare this to a story in Australia. There are fears that thousands of patients at a clinic may have been infected with HIV, hepatitis and other diseases after hygiene standards were found to be seriously deficient. The clinic has been closed while the investigations take place. I don't know of any similar investigation in an African country and I've rarely heard of a hospital or clinic closing merely because patients health and lives may be at risk.

Endoscope and biopsy equipment were found to have been insufficiently sterilized after nine patients became sick. There was also a contaminated anaesthetic involved. These are problems that African hospitals face all the time. They often don't have the equipment to sterilize everything properly, nor even enough trained staff to carry out the work. African hospitals also have the problem of old equipment, shortages of equipment and the need to reuse things that are designed to be disposable. Health workers are not going to do without gloves just because there is a shortage. How many options do they have?

In Australian hospitals, people are far less likely to be infected with HIV, hepatitis or other serious illness. But in African countries, where only the sickest go to hospital and many serious diseases are endemic, the risks are very high. But patients becoming ill after receiving medical treatment in African hospitals is so common that this is unlikely to trigger any kind of investigation, as happened in the Australian instance. And if people die, there are unlikely to be any questions asked. Many people die every day of all sorts of things. Health workers have little enough time to deal with sick people, let alone dead people.

In the UK, children who may have been jabbed with discarded hypodermic needles in a paddling pool are being monitored for HIV and other conditions. The have to wait three months to be sure they have not been infected with HIV, but at least they and their parents were alert to the fact that they may have been contaminated. I have passed through a couple of health facilities in East Africa and seen needles and other sharps in the grass where people walk in rubber sandals and where children play. I wonder if African children running around in bare feet would even notice a pinprick or scratch from a needle.

But I know that the parents of most children here would have no idea that needles and other hospital wastes carry a risk of infection with HIV and other diseases. Some people can tell you that sharing needles and the like carries a risk but most have not been fully warned about the risks associated with medical and cosmetic facilities. Indeed, the official line is that there is only a tiny risk from medical and cosmetic transmission of HIV. Those responsible for the official line, UNAIDS, WHO, CDC and the rest, must be well aware that non-sexual risks are far higher than they admit. But for some reason, they don't want Africans to know that these risks exist and, consequently, how to protect themselves.

And so, as the Western world worries about Westerners going to the World Cup being infected with HIV through some kind of sexual encounter, it's quite amazing that there are no warnings about non-sexual risks. Football supporters don't just like drinking and having sex after matches, they also like fighting, especially when their team loses. And drunk people can be prone to all sorts of accidents. People will end up in accident and emergency wards, dental surgeries and the like. People also may like to get that special football tattoo in South Africa, where it may be cheaper, but also more dangerous.

No doubt, there will be the usual slew of stories after the event about how various efforts and initiatives failed and how things should have been done differently. Journalists will never close the stable door if they can make a story about the bolted horse. So if the media, websites, officials and other sources of information will say nothing about non-sexually transmitted HIV, instead concentrating exclusively on sexual transmission, there will also be stories about how people are let down by health services and how unhygienic tattooists, hairdressers and ear piercers are. But only when it is too late for the victims.

If the Western press is really so worried about the health of Westerners, they should highlight the risks of non-sexually transmitted HIV and other health risks that people receiving medical and cosmetic treatment in South Africa face. They clearly are not worried about the risks that South Africans face and will continue to face after the World Cup has ceased to be front page news. But there is hope that South Africans themselves will one day question the official line, that they have so much sex that this explains why the country has more HIV positive people than any other. South Africans themselves may question the state of the health services that are available to them and ask why they have not been warned about non-sexual HIV risks or how to protect themselves. This is a very good time for them to raise these questions, before the Western press goes back to seeing Africa as a far away place populated by foreigners who have a lot of risky sex.

UNAIDS Set to Score Own Goal in South Africa

Many people who follow the HIV pandemic will be looking with interest at the soccer in South Africa or rather, reports about possible HIV transmission there. There are claims that tens of thousands of women from around the world are flocking to South Africa to work in the sex industry and that a lot of soccer fans will be availing of these services. Whether these claims are true or not is anyone's guess, I've seen no evidence to back them up.

It seems likely that even if people visiting South Africa don't know how to protect themselves, those working in the sex industry will. One hopes so, after decades of warnings about the dangers of sex and HIV. If these warnings haven't worked by now, perhaps those spending public money on them should rethink their HIV strategy.

But what about the dangers of non-sexual infection with HIV? Neither those in the West coming over to South Africa nor those living in South Africa are likely to have had so many warnings. Tourists may well be aware of non-sexual risks, such as tattoo parlours, cosmetic outlets like barber shops and, perhaps most importantly, medical facilities. Go into a travel shop in many European countries and you will find medical equipment that you can bring with you on your trip, such as needles, syringes and sutures. Some of the well known guide books warn against some of the non-sexual dangers of HIV infection in addition to sexual behaviour.

Africans are not granted the benefits of access to affordable medical equipment or even of information about non-sexual HIV risk and how to protect themselves. It seems they are just not as important as tourists and others visiting the continent.

Perhaps Westerners visiting South Africa have some chance of protecting themselves against these risks, although the media coverage of the issue is (as usual) concentrating on sexual risk. In a typical article covering the soccer, we can read about sporting stars and what they have to say about HIV and sexual violence, especially against women and girls. I assume they are saying what they are told to say, perhaps what they are paid to say, but none of them appear to be talking abut non-sexual transmission of HIV. Or perhaps the press just doesn't bother covering that issue.

My guess is that people's heads, wherever they come from, have been so filled with information about condoms, casual sex, multiple partners and the rest, non-sexual risks will have little impact. And conflating gender based violence with HIV risk is not very helpful either. Gender based violence, whoever the victims, is wrong, it's not just wrong because victims may be infected with HIV. In fact, the majority of victims are not infected with HIV, but gender based violence is none the less abhorrent.

In a similar vein, an article about the singer Annie Lennox becoming a Goodwill Ambassador for UNAIDS also conflates the need to reduce HIV transmission with the need to fight against gender based violence. I admire Annie Lennox and I hope she gets through to people in a way that UNAIDS has completely failed to do. But being supported by UNAIDS would tend to suggest otherwise. Still, Lennox is an intelligent and sincere woman. We may see her shaking off the shackles of UNAIDS patronage and speaking the truth about HIV.

The truth is that the mainstream HIV industry has concentrated on sexual transmission of HIV to the exclusion of medical or cosmetic transmission. This was not so much the case in the early days, before the interference of massive levels of funding, commercial, political and religious interests. But now, the industry is all but silent on anything but sexual HIV transmission.

This is not because UNAIDS, the UN, WHO, CDC and other big players don't know about non-sexual HIV transmission. They have just chosen to ignore it. It's not quite clear why and I'd really like to hear their explanation. However, they simply spew out their guesswork figures, which already presuppose that heterosexual transmission accounts for most HIV transmission in African countries. They assume sexual transmission to be so high that there is not much scope for estimating anything more than a few percent for non-sexual transmission, unless the number of transmissions is higher than 100%, which wouldn't be beyond those clever UNAIDS epidemiologists. They can do anything with figures, it appears, except tell the truth.

Even campaigns about sexual transmission of HIV have been unconvincing, to date. But they are better than the complete silence that non-sexual transmission receives. People just don't realize the number of risks they face in their day to day lives. And people in African countries face more of those risks than those in Western countries. For a start, HIV prevalence is already very high in many Sub-Saharan countries. But medical facilities are often understaffed, underfunded, underequipped and oversubscribed. This is a disasterous combination if you consider how efficient medical transmission of HIV is, compared to sexual transmission.

Whatever happens during the World Cup, there will be little point in investigating what went wrong with the campaigns afterwards. The World Cup itself is irrelevant to the fact that millions of Africans face etremely high risk of contracting HIV every day and this has little or nothing to do with their sexual behaviour. The evidence for that is available now. It's time international health institutions stopped ignoring it.

HIV Stigma and Institutional Racism

The received view about HIV these days is that unless you are a gay man, a sex worker or an injecting drug user, you are unlikely to be infected. At least, that’s the received view in rich countries. In fact, in their 2009 Aids Epidemic Update, UNAIDS don’t even mention sex workers for North America and Western and Central Europe. They say “[i]n North America and in Western and Central Europe, national epidemics are concentrated among key populations at higher risk, especially men who have sex with men, injecting drug users and immigrants”. Despite this though, heterosexual sex appears to account for about 30% of transmission.

But in poorer countries, especially in Africa, the received view is somewhat different. Here, it is claimed that the most common way of spreading HIV is through heterosexual (vaginal) sex. UNAIDS say “[h]eterosexual intercourse remains the primary mode of HIV transmission in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies.” They even claim that 94% of transmission is by heterosexual sex in Swaziland.

But the report goes on to suggest, effectively, that low risk sex is high risk sex in Lesotho and Kenya because it accounts for most transmission. “In Lesotho, between 35% and 62% of incident HIV infections in 2008 occurred among people who had a single sexual partner. Heterosexual sex within a union or regular partnership accounted for an estimated 44% of incident HIV infections in Kenya in 2006, while casual heterosexual sex accounted for an additional 20% of new infections”. However, if low risk sex is high risk, this just begs the question of how sexual behaviour could account for so much transmission in some countries but not others. Most people in every country have low risk sex but most countries don't have high HIV prevalence. UNAIDS accept that gay men and drug users are also at high risk, but that they contribute far less to the epidemic.

According to this received view, sex workers in African countries would be particularly at risk, along with their clients and their clients’ other sexual partners. So it’s easy to see how stigma creeps in. If you become infected with HIV, you are probably a prostitute, someone who frequents prostitutes or, even worse, a gay man or an injecting drug user. Because of the stigma attaching to HIV, people are often less quick to see that there are many who could have been infected unwittingly. And the issue of infants being infected by their mother can also be an inconvenience when painting a picture of rampant illicit sex and drug taking.

A former UNAIDS employee, Elizabeth Pisani, says “HIV is mostly about people doing stupid things in the pursuit of pleasure or money”. She also says “In Africa, people are contracting the virus through heterosexual, non-commercial sex”. Pisani is someone who certainly knows how to reinforce stigmatizing views. I’m surprised she ever left UNAIDS.

Of course, heterosexual sex would account for a substantial proportion of HIV transmission. But how substantial is anyone’s guess. Because, holders of the received view claim that HIV infection through accidental blood exposure in poor countries is low or negligible. Back to UNAIDS again: “A small percentage of prevalent HIV infections in sub-Saharan Africa is estimated to stem from unsafe injections in medical settings.” Also: “In an analysis of data from Kenya, medical injections were estimated to be the source of 0.6% of all HIV infections”. Though strangely enough, they admit that medical transmission is far more significant in Uganda.

They even find that in Eastern Europe and Central Asia “[i]n addition to new infections associated with injecting drug use and unprotected sex, key informants and scattered media reports suggest that a notable number of new infections may be occurring as a result of unsafe injections in health-care settings.” However, what they mean by ‘key informants’ etc., actually refers to a whole body of evidence about unsafe injections that UNAIDS are unwilling to countenance, so they ignore it.

In hospitals and clinics in developing countries, instruments that are contaminated with blood and various blood-borne diseases may be reused or inadequately sterilized. Health services are underfunded, understaffed and short of resources. There is no lack of evidence that they are risky places. So how can UNAIDS come up with these figures for medical transmission of HIV? Well, by being selective about what evidence they cite and by ignoring anything they don’t like the look of. High rates of medical transmission, and consequently, lower rates of sexual transmission, doesn’t fit with the view that, in Africa, people have a lot of unsafe sex. And institutions, politicians, churches and funders are interested in supporting sexual behaviour change programmes.

These same people are probably not interested in accepting that some of the problem may arise from unhygienic practices in the very health facilities where they are urging people to go for testing and treatment. The mainstream doesn’t want to see itself as being a significant part of the problem. So UN and WHO personnel, diplomats and other high ranking officers are issued with their own needles and syringes when they are visiting African countries. They are also given instructions to avoid treatment if at all possible.

But Africans themselves are supposed to visit whatever health facility is available to them without even a warning about the risks they face or the precautions they can take. And if they are infected with HIV, they will probably unknowingly go on to infect others.

It seems to me that racist attitudes allow members of institutions such as UNAIDS to assume that Africans have lots of unsafe sex, but that most non-Africans don’t. And racist attitudes allow these institutions to recommend that their employees avoid medical facilities in developing countries, without doing the same for people who have to live in those countries.

In Western countries, people travelling to African countries are likely to be made aware of some of the potential risks of visiting medical facilities there. They can buy information about medical safety and even kits containing syringes, needles and the like, so they can reduce the risks they face further. If it is so important for Westerners visiting African countries to take care when visiting medical facilities, or even to avoid visiting them altogether, why is it not equally important to protect Africans from being infected in these facilities?

Why is HIV Stigmatized and How Can We Reduce Stigma?

When HIV was first identified as the virus that causes the syndrome now known as Aids, it was quickly established that it could be transmitted through exchange of bodily fluids, blood, semen, breast milk and through other routes. This means that it can be transmitted through sexual contact, through blood contact (during medical and cosmetic procedures, also by intravenous drug users) and from mother to child (also called vertical transmission).

Nearly thirty years later, sexual transmission is still the mode of transmission that gets the most attention. The received view, supported by organisations such as UNAIDS, the WHO and others, is that the vast majority of HIV positive people in African countries were infected through some form of sexual contact. Of course, many probably were. But heterosexual transmission is not the most efficient mode of transmission. In fact, it is a relatively inefficient mode of transmission.

Mother to child transmission is an efficient mode of transmission without medical intervention. But with medical intervention, transmission is low, even in developing countries. Now, in countries like Kenya, an increasing number of pregnant women are being tested for HIV as soon as they start attending ante-natal clinics. They are usually monitored and treated if they are found to be HIV positive in order to prevent transmission of HIV from mother to child.

However, exchange of contaminated blood is a very efficient mode of transmission, whether it occurs through intravenous drug use, a visit to the doctor or even a visit to the beautician. One hopes that all the public information and education there have been about the risk of contracting or transmitting HIV through exchange of blood would make people aware of these risks, whether they are drug users, health care workers, patients or clients of hairdressers.

But as I have said, sexual transmission is the mode that has received the most attention. It has and continues to dominate HIV prevention programmes with any other modes of transmission receiving far less attention, if any.

So what is the meaning of the received view of HIV, that 80-85% of it is transmitted sexually? In particular, why would HIV prevalence in Greece be .008% when prevalence in Kenya is 8% and prevalence in Lesotho is 28%? Does this mean that Greeks have orders of magnitude less sex than people in Kenya and Lesotho?

Well, for a start, UNAIDS distinguishes between generalised and concentrated epidemics. Countries with generalised epidemics usually, but not always, have high HIV prevalence, above 1%, and affecting people who are not in groups thought to be at especially high risk. Those at high risk include men who have sex with men, intravenous drug users and commercial sex workers. Greece has a low level, concentrated epidemic. Those infected in Greece are almost all in one of those high risk groups.

In contrast, Lesotho and Kenya have generalized epidemics. According to UNAIDS, the WHO and others, sexual behaviour explains high prevalence of HIV in these two countries, but not in Greece. They say that risky sexual behaviour such as unprotected sex, high numbers of lifetime partners, high levels of concurrency (having sexual relationships with several different people where those relationships overlap to a significant extent) and others are responsible for the terrible HIV epidemics of the sort found almost exclusively in Sub-Saharan African countries.

The claim, then, is that people in these countries indulge in more risky sexual behaviour, but how much more? It would need to be a great deal more but there is little or no evidence to show that this is the case. Rather, when people are diagnosed as HIV positive in African countries, it is assumed that they were infected sexually, either by their main partner or by some other sexual contact. If their partner turns out to be HIV negative it is assumed that they had sexual contact with someone else.

Many people have been diagnosed as HIV positive and it has turned out that their partner is HIV negative. It is then assumed that the HIV positive partner, often the woman, had an affair with someone else. If she denies this, it is assumed that she is lying. Although that’s the case in Kenya and Lesotho, it’s unlikely to be the case in Greece or any other Western country. The assumption that people are just lying partly stems from the received view: that 80-85% of HIV is transmitted sexually in countries with generalized epidemics. Some may lie, but some may lie in Greece too. So how many instances like this have been investigated? In African countries, precisely zero.

Consider another phenomenon: infants and children who have been found to be HIV positive when their mother is not. It’s harder to claim that so many infants and children have been, one, sexually assaulted, two, sexually assaulted by someone who is HIV positive and three, that they were infected as a result of this sexual assault. South Africa recently found quite a worrying number of HIV infections among children who were not sexually active and whose mothers were not HIV positive. Further research was called for, into the possibility of sexual assault and the possibility of medical transmission. Neither, as far as I know, has yet been carried out.

Accepting that HIV is mostly transmitted by heterosexual intercourse means accepting that a lot of people are having a lot of unsafe sex with a lot of other people over a long period of time. It involves accepting that this happens in Sub-Saharan African countries to an extent not found in most other countries, indeed, to an extent that is just not credible.

If unbelievably high rates of risky sex are a figment of the imagination of those who work for or who follow the pronouncements of UNAIDS and WHO, what could account for all the generalized epidemics in Africa?

A number of suggestions have been made (by those who dare to diverge from the received view). Some have suggested that low levels of health care and education and high rates of poverty in many African countries make people more susceptible to HIV infection. But, while it is true that these circumstances are found in many African countries, they are also found in countries where HIV prevalence is far lower. And even in African countries, HIV prevalence has often been higher among the rich and well educated.

A better suggestion is that high rates of disease and low levels of nutrition make people more susceptible. Many preventable and treatable conditions, such as TB, malaria, human parasites and certain sexually transmitted infections have been shown to significantly increase the risk of HIV transmission, especially sexually, though also through blood contact and through vertical transmission.

But then this doesn’t really explain why well off and well educated people were infected in greater numbers than poor and badly educated people, especially in the early stages of the epidemic. Well off and well educated people would be less likely to suffer from these conditions and would have had better access to healthcare.

It’s time for people to question the idea that inordinately high levels of unsafe sex in certain African countries can fully explain the high prevalence of HIV found there. We need to re-examine all other modes of transmission, especially where blood exposure could be involved. Barbers’ and beauticians’ shops don’t always look too sterile. But nor do hospitals and clinics. Putting it a different way, it must be wondered how the sort of badly equipped, understaffed, overcrowded facilities found in African countries can avoid transmitting HIV and other diseases, at least sometimes. Questions about the safety of health and other facilities urgently need to be raised.

The received view, that 80-85% of HIV transmission in Sub-Saharan African countries has been through sexual contact, can not be correct. How much can truly be put down to sexual transmission is unclear because a lot of the research has just not been carried out. What research has been done has been ignored because it contradicts the received view. But we owe it to people who are HIV positive, despite never having engaged in unsafe or illicit sex, to do this research. We owe it to everyone who is HIV positive because we don’t know how they became infected. They may not even know themselves. The stigma comes from an assumption that we are not entitled to make.

If, as some people would argue, a substantial amount of HIV was transmitted by non-sexual means, perhaps a lot by medical transmission, this could explain why HIV reached levels where even sexual transmission started to become far more significant than in other countries, where prevalence remained low. Most children and pregnant women, especially, receive a lot of injections and other medical treatment and a very common form of contraception is given by injection. And many other people in African countries also receive a lot of injections, for example, commercial sex workers and men who have sex with men. The highly efficient transmission of HIV that would occur through blood exposure could quickly spread an infection to many people. There is no evidence that the same rates of transmission could occur through sexual transmission alone, even if risky sex was as common as claimed by the received view.

Reducing stigma is always going to be a difficult task, whatever its target. But it should be easier to reduce stigma once it is clearer how HIV really reached such high levels of prevalence in some countries and not others. Sexually transmitted HIV could only have infected large numbers of people once a high prevalence of HIV had already been reached through some other mode. Research to establish how HIV reached present levels is urgently needed, starting with medical and cosmetic transmission.

HIV is stigmatized because of the received view that it is mostly transmitted by heterosexual sex in Sub-Saharan Africa. However, rates of unsafe sex would need to reach incredible levels for this received view to be correct. Though stigmatizing sick people should always be avoided, there must be other reasons than sexual behaviour to explain why HIV prevalence is so high in some African countries, reasons which would show that this stigma is misplaced. Those who are infected through non-sexual routes, of course, can also go on to transmit HIV sexually. Therefore, a large amount of sexual transmission, which can occur once HIV infects a critical percentage of the population, can also be partly attributed to non-sexual transmission. Some, perhaps most, of this non-sexual transmission may come from unsafe medical and cosmetic practices.

Health Aid: Supporting People or Supporting Indicators?

While news that maternal mortality has been decreasing since 1980 has been welcomed by many, others point out that a significant contributor to maternal mortality is HIV. A lot of attention and resources go towards mother to child transmission of HIV (MTCT), but very little go towards the health and survival of the mothers. Concentration on the single indicator of numbers of infants infected by their mothers, also called vertical transmission, seems to have left the health of HIV positive mothers out of the picture.

Of course, it is madness to ignore the HIV status of the mother, for many reasons. For a start, mothers are people too, not just 'cases' or carriers of disease. They, like their children, husbands and other family members, are entitled to health and to treatment when their health is compromised. And it would be madness too to ignore any other diseases, in mothers and children or anyone else. But health funding is mad. Hence the selection of a few headline grabbing indicators.

HIV positive mothers can go on to transmit HIV to their infants at a later stage, through various routes, or to their partners. They are at risk of dying from Aids related illnesses or of suffering from serious and prolonged illnesses. These will also have an impact on the health of their children and other family members. Even the MTCT prevention treatment (PMTCT) can lead to drug resistance in mothers. In developing countries this can seriously affect the chances of the mother being successfully treated or cut the length of time that the treatment remains effective.

It seems extraordinary that health funders still take this piecemeal approach to disease reduction, even when it directly affects their chosen indicator(s). Unsurprisingly, the report was funded by the Gates Foundation. They particularly favour somewhat rarefied approaches to health issues, selecting the bits that they are interested in and leaving the rest. For example, the foundation is interested in finding a vaccine for cholera but not so interested in clean water and sanitation, which could reduce incidence of numerous water related health issues. (They give small amounts of money to water and sanitation projects but nothing like the amount going to vaccines and the like.)

A particularly worrying aspect of approaching MTCT in this piecemeal fashion is that as many as half of infant infections may result from mothers who were infected while they were pregnant or whose positive status was not detected while they were pregnant (perhaps because they were in the 'window' period, where they had not yet seroconverted). This occurred in a PMTCT programme in Malawi, considered to be one of the best. Another survey found that such missed maternal HIV infections resulted in a high percentage of infants being born HIV positive. Ironically, the paper also concludes that recently increased child mortality rates in KwaZulu-Natal could be caused, in part, by increased maternal mortality.

It has been suggested that this may be a potentially useful role for pre-exposure prophylaxis (PrEP). PrEP involves putting HIV negative people on antiretroviral drugs, usually where they are thought to be at particular risk of infection. Of course, some of these women may not have been infected through sexual intercourse. It is not even clear from the article whether the mothers of infants subsequently found to be HIV positive were also re-tested or were just assumed to be positive because their infants were. Apparently, an unusually high percentage of women who were not found to be HIV positive before delivery were later found to have HIV positive infants.

Concentrating on one disease or on that disease in one demographic, or even looking at absence of sickness as the only criterion for health, is not going to ensure the health of whole populations. The dominant approach to HIV and the almost universal adherence to the behavioural paradigm (the view that the disease is predominantly sexually transmitted) is wrong for many reasons that have been made clear, in particular, by our lack of success in significantly slowing the pace of transmission. It's time to look at HIV as being part of health as a whole, as being related to the totality of conditions in which people live and work.

If we continue to fail to ensure good health services, education, nutrition levels, food security, infrastructure and numerous other conditions, all diseases, including HIV, will continue to spread. This will reduce people's quality of life and life expectancy. Self serving reports that show how well some favoured indicator is doing should be seen for what they are. Billions of people still suffer from and die from preventable and treatable diseases every year. That's nothing to celebrate.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Malawi Needs Good HIV Research, Not Bad HIV Laws

Malawi has this cunning plan to 'outlaw HIV transmission' by making it a crime to 'knowingly' transmit HIV. A spokesperson for the ministry involved said "The underlying factor is that if anybody knowingly infects somebody...that means he commits an offence." I haven't been able to find a copy of the bill but apparently it means that if a HIV positive sex worker fails to let partners or clients know their status, they will be liable to prosecution.

I wonder if their partners or clients will also be liable to prosecution for failing to reveal their status. After all, people availing of the services provided by sex workers should be equally aware of the danger of transmitting and of being infected with HIV, along with various other sexually transmitted infections (STI). The spokesperson was unable to say what would happen if both parties were HIV positive and referred to the bill as a challenge. He also said what they are doing is educating the populace. I assume he was trying to make a joke, however inappropriate.

I would also like to know where the law would stand with regard to non-sexual transmission of HIV. For example, where health services use shared needles, syringes or medicine vials or engage in other potentially hazardous practices, would they be liable to prosecution? Supposing they failed to take precautions specified under normal occupational procedures, how would the law stand? Could a HIV positive mother be accused of criminally infecting her child, either in the womb, during birth or through breastfeeding? Would a HIV positive intravenous drug user (IDU) be liable by sharing injecting equipment?

If you accept the received view of HIV transmission and believe that 75% of it is transmitted through heterosexual sex and only a very minor proportion through unsafe medical procedures, you may not worry about medical transmission (though this doesn't answer the questions about IDUs or transmission by mothers to their children). But if doubt were cast on that received view, if medical transmission were more common than previously supposed (admitted?), or if it were even more common than heterosexual transmission, you might consider the question more important, especially if you were a health professional.

The trouble with medical transmission of HIV is that it has received very little research. Figures you hear bandied about are mostly based on assumptions which should never have been allowed to stand untested, as they have been, for several decades. But among the few bodies of data that have been collected, medical transmission has been found to be a risk in almost all of them. This doesn't mean that medical transmission has been demonstrated, just that those receiving injections have a higher risk of subsequently being found to be HIV positive. Notable also is the fact that some of this research goes back to the mid 1980s.

Data from Malawi is the most shocking. 54% of HIV infections are found among those who have received injections in clinical settings. Other countries report lower percentages but the average is 21% and the mean is 19%. For me, the worst aspect of this is that none of these pieces of research are national in scale and only a handful of countries are involved (DRC, Uganda, Rwanda, Tanzania, Zimbabwe and Malawi).

The Malawian spokesperson is right in saying that there no straightforward answers to questions that arise about this proposed bill, but not for the reasons he thinks. If medical transmission of HIV is higher than has been previously assumed, it would be more worthwhile, indeed, more straightforward, to investigate this and provide some remedies. That would certainly be more feasible than trying to create laws of dubious ethical standing to reduce HIV transmission.

On the whole, it would be a good thing if HIV was less likely to be transmitted sexually because it is difficult to influence the sexual behaviour of whole populations and efforts so far have failed. In contrast, it should be much easier to influence the practices of existing health personnel, increase the number of trained personnel, increase the resources available to them and increase access to health services. And improving health services will have benefits that far exceed those to HIV alone. As to how providers of medical services can regain the trust they will have lost, that will be no easy matter. But I don't think anyone would opt for continuing to transmit HIV through medical procedures, if this is actually happening.

The admission that medical transmission of HIV could be higher than previously thought, and even that sexual transmission could be lower, may be a hard one to make. Of course, it may not even be true that medical transmission is higher and sexual transmission is lower. But now that the possibility has been raised, we can not continue to fail to research this vital area of HIV knowledge. Let us stop lying about what we don't yet know.

The Biggest 'Omission' in Medical History?

Sometimes you come across a theory that can explain so much that you wonder why you have been flailing around hopelessly for so long. One time I was looking around one of those electronics shops that you find in every terminal in London's airports. I was marvelling at the things that can be made and even purchased at fairly reasonable prices. Because I was studying development at the time, I was trying to think why the sort of ingenuity that that goes into these products, which were hardly vital to humanity, didn't go into development. The proto-theory I came up with was that some people just don't matter.

I was horrified that this thought could go through my mind just then, because it is a value judgement, not a scientifically testable theory. Surely it has no place in development theory, especially in the specific area of HIV research, a field peopled by some of the most brilliant scientific minds alive? But the thought never left my mind because it seemed to explain so many things. How else could you explain the way people in rich countries treat people in poor countries? The more I studied, the more I realised that some people believe that (or behave as if) other people don't matter, either because they are far away, they are foreign, they are poor, they are sick and needy or are just not worth considering.

While studying HIV, I was unconvinced that the entire explanation for the rate of HIV transmission, in some countries only, could be explained purely by differences in sexual behaviour. I was equally unconvinced that so called HIV prevention programmes could possibly have any influence on sexual behaviour. And when countries boasted about how successful they were in reducing HIV transmission as a result of these prevention programmes, I thought they were unclear about why HIV prevalence had dropped and didn't really care why, they just used the circumstance for publicity.

I had to limit my study to make it manageable and did so by concentrating on heterosexual transmission of the virus, since it is the received view that this is the main mode of transmission in countries with a generalised epidemic, such as Kenya. And it turns out that that is one highly dangerous received view, for many reasons. Heterosexual transmission of HIV is definitely one mode of transmission, but the extent to which it drives generalised epidemics is completely unclear, and it always has been.

So my objection to the main players in the HIV industry is this: why has so much money and effort gone into programmes that assume the precedence of heterosexual transmission when this is just an assumption? The whole idea that there are some people who have more sex than others, or more sexual partners, or who are more likely to engage in unsafe sex, is a value judgement. But it is the value judgement that has launched a thousand careers for politicians, religious leaders, social and religious leaders, professionals of all kinds and who knows what else. It is a value judgement that drives global HIV prevention policy and spending.

There are many warning signs that heterosexual transmission of HIV does not explain extremely high rates of transmission in some countries. No credible correlation has ever been found between rates of transmission and levels of the kind of sexual behaviour that would be required to drive the sort of epidemics found in Kenya, South Africa, Lesotho, Swaziland and anywhere else. There are so many contradictions and non-correlations that many professionals in the HIV industry must have been asleep since some time in the 1980s, because there were obvious problems with the sexual behaviour paradigm even then.

Even back in the 1980s, not long after HIV was identified as the virus that caused AIDS, medical transmission was recognised as one of the possible modes of transmission. Small amounts of research went into establishing the extent of unsafe medical practices and the results suggested that these practices could transmit HIV to many people. But little further research was carried out. WHO, various UN agencies, leaders of all descriptions, professionals of all descriptions, various globally represented organisations, institutions, universities and others flew the flag for heterosexual transmission of HIV in developing countries (though not in developed countries). There were few exceptions and they were considered to be denialists or trouble makers. There are still few exceptions and they are still considered to be denialists or trouble makers.

Well, maybe medical transmission of HIV is not very high, maybe it is lower than heterosexual transmission. Maybe all the fuss is about nothing and maybe I'm just one more person poking his nose in where it doesn't belong. But that is the point: I want to know why medical transmission of HIV has not been properly investigated, why it is still dismissed as being almost non-existent. The recently published (though based on out of date data) Modes of Transmission Survey for Kenya suggests that medical transmission accounts for 0.6% of all transmission, based on an assumption that seems to have been pulled out of thin air. They also note a finding that puts the rate at 2%, over three times higher. But this is still dwarfed by most of the other modes of transmission, especially heterosexual transmission.

But those who are still being branded as mavericks for questioning the received view point to many bodies of data that have managed to investigate medical transmission rates of HIV. Those bodies of data show that medical transmission is very significant, perhaps even more significant than any other mode of transmission, including heterosexual transmission. All they are asking is that these results be taken seriously and subjected to rigorous testing. If medical transmission of HIV even stands at 5%, this would still account for millions of people currently living with HIV and hundreds of thousands of people who have died of HIV.

One of the most heartrending things about people dying of HIV, as opposed to other diseases, is that they are, because of the unexamined and long held value judgements of so many 'brilliant minds', vilified, ridiculed, shunned, persecuted, sneered at and humiliated just when they are in most need of sympathy, love and basic humanity. If it is even remotely possible that we as people are guilty of such terrible injustice to fellow human beings, surely that is in urgent need of investigation? Far from dying because they have engaged in what may or may not be risky sexual activity, people may be dying because they have followed the advice of well educated professionals.

It's almost unthinkable that much, or even any, recent cases of HIV have been transmitted by the very professionals that are supposed to be preventing and treating HIV. But it is even more unthinkable that we could suspect such a thing is happening and do nothing about it. Maybe there is a danger that people will stop going to health professionals and stop seeking medical treatment, even vital vaccinations and life saving treatment, because of a complete lack of confidence in the profession. But that is something the profession will have to deal with because they certainly don't deserve any confidence or respect until they have fulfilled obligations that have so long been outstanding. In fact, in some countries, going to the doctor may curently be a health hazard, carrying risks of infection with HIV and many other blood borne diseases.

In the field of HIV, nothing is more important right now than establishing the extent of HIV transmission through medical treatment.