Millennium Development Goals For All, But At All Costs?

A survey was carried out in one district each in Kenya, Tanzania and Zambia to establish which factors are associated with health facility childbirth (thus shedding light on which factors are associated with the decision to give birth elsewhere, perhaps at home). Health seeking behavior is strongly associated with wealth, education, and urban residence; wealthier, better educated women living in urban areas, in general, are more likely to give birth in a health facility.

These factors are of especial interest because of their association with HIV. Wealthier, employed, better educated, urban dwelling women in African countries are often more, rather than less likely, to be infected with HIV. The tables below are for Kenya, Tanzania and Zambia, but these trends can also be found in other countries. The first table shows HIV prevalence by wealth quintile, with prevalence being lower among poorer people and higher among wealthier people.

The next table shows HIV prevalence in males and females, by employment and by urban/rural residence. Males are far less likely to be infected than females, unemployed people are less likely to be infected than employed people and rural dwelling people are less likely to be infected than urban dwelling people.

The third table shows that HIV prevalence is sometimes lower among those who have less education and higher among those with primary education in Kenya and Tanzania and those with secondary education and beyond in Zambia. (Note, figures for education are for attendance, not attainment, so they don't tell you that much. But MDG 2 is about 'achieving universal primary education', not about academic attainment.)

Receiving antenatal care at a health facility is part of the Millennium Development Goal (MDG) number 5, to improve maternal health. Therefore, it is not surprising that all 14 African countries I have looked at have a very high score for this goal, all ready for 2015. But the goal does not consider matters such as conditions in health facilities, skills of providers, facility practices, equipment, supplies, etc. So the percentage of women delivering in health facilities and the percentage of deliveries attended by a skilled health provider are far lower, being out of the MDG limelight.

For information on health facility conditions, equipment and supplies, there are Service Provision Assessments for each of the three countries, showing that there are many serious lapses. But questions about whether skilled providers are skilled, and of how skilled they are, are less often asked (particularly in relation to the MDGs). Another paper, entitled "Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward", addresses this issue.

Skill levels overall are not impressive and are low in some areas in the countries involved (Nicaragua, Benin, Ecuador, Jamaica and Rwanda). The researchers note that "knowledge of a procedure is no guarantee that it can be performed correctly", but also that problems are not solely due to a lack of skills or training, that some are due to lack of equipment, supplies and other things.

The first article estimates that skilled birth attendance could substantially reduce maternal deaths "presuming that facilities meet standards of quality care." Quite. But various sources of data show that health facilities often don't meet standards of quality care. The possibility that health facilities may be the source of a considerable proportion of HIV infections in high prevalence countries must be considered urgently if healthcare transmitted HIV, and other diseases, are to be averted.

Reducing maternal deaths is a laudable goal, but it is nothing short of unethical to encourage women to attend health facilities where the conditions are likely to be unsafe. Right now, failing to achieve MDG 5 may even be preferable to achieving it. Of course deaths from hemorrhage, obstructed labor, puerperal sepsis and pre-eclampsia must be reduced, but not at the cost of increasing incidence of HIV, hepatitis and other bloodborne diseases.

When Will UNAIDS Be Abolished?

When people find used hypodermic needles in areas where children play in Western countries, they are upset. Quite rightly so. They don't like the thought that their children are being exposed to injury and diseases, possibly even serious or deadly diseases.

But even many Westerners seem to believe that HIV 'dies' within seconds, minutes or some fairly short period, outside of the body. This is not what the US Center for Disease Control (CDC) says on the subject, although it may have said that at one time. Their current answer to the question 'How well does HIV survive outside the body?' is difficult to interpret.

But no matter how you interpret the risk, no one wants a possibly contaminated needle piercing their skin or that of their children. As well as the physical injury, there is also a risk that the needle is contaminated with hepatitis and it is almost certainly contaminated with bacteria.

So the CDC's comment about 'incorrect interpretations' of risk causing 'unnecessary alarm' seems injudicious. I know the question is about HIV but the answer really needs to address risk as a whole. Potentially, HIV can survive for days and even weeks, under the right conditions. Contact with contaminated needles and other instruments should be avoided and where this is not possible, medical advice is required.

However, the idea that the HIV does not live outside the body is widely held, by professionals and lay people. And in countries like Kenya, Tanzania and Uganda, it is far more dangerous to be unaware of the risks. The chances of medical or cosmetic equipment being contaminated in countries with high prevalence of HIV, hepatitis and other diseases can be very high.

You might think that there would be a lot of awareness of these risks and how to avoid them but I have rarely spoken to anyone who has considered the risks they face from contaminated instruments in health or cosmetic facilities.

UNAIDS dismisses the importance of any form of non-sexual HIV transmission, let alone transmission in health facilities. They grudgingly accept that a few percentage points of HIV transmission in East African countries may come from such routes. But they hardly mention cosmetic instruments, razors, tattooing equipment and the like, at all.

As a result, such transmission may be occurring at high rates and people are doing nothing about it. When they take their child to the hairdresser, or go themselves, they could be picking up scabies, hepatitis, HIV or some kind of bacterial infection. To help people avoid these risks, the best thing to do would be to inform them.

Risks in health facilities are more difficult to handle. Doctors, nurses and other health personnel can be pressed for time and it is not easy for patients, or those accompanying patients, to intervene. At best, personnel will be annoyed, at worst, they will refuse to treat the patient, give them poorer quality treatment or make them wait a long time.

The WHO has published data showing that as much as 14% of injections in developing countries are contaminated with HIV and they have unpublished data showing that this figure can be a lot higher. A large proportion of hepatitis B and C is transmitted through contaminted needles. And an estimated 70% of all injections are not even necessary.

When there is even the hint that someone in a Western country may have come into contact with contaminated equipment, there is an investigation to establish how procedures could have resulted in such a risk. And anyone who may have been affected, even going back years, and through thousands of records, is contacted and screened.

Not only does this sort of investigation and screening of possible use of contaminated equipment not take place in developing countries but UNAIDS and others seem keen to deny that such things, which happen in the best resourced health systems in the world, could possibly happen in the worst resourced health systems in the world.

The Dogmatic Sexualization of HIV

The main thrust of this blog has been to challenge the 'behavioral paradigm', the view that HIV is almost entirely transmitted by sexual behavior in African countries (The figure '90%' is often bandied about but there is no evidence for it). Therefore, any articles that either support or challenge the behavioral paradigm are of particular interest. As for the belief that the paradigm only holds for African countries, it is difficult to see that as anything other than racism.

A group of people led by Munyaradzi Mapingure have published a paper suggesting that the behavioral paradigm may need to be reconsidered in the light of their findings. They discuss sexual behavior data for Zimbabwe and Tanzania which clearly does not correlate with HIV prevalence. Zimbabwe has some of the highest HIV rates in the world while Tanzania has relatively low HIV prevalence. Yet levels of 'unsafe' sexual behavior are far higher in Tanzania than they are in Zimbabwe.

This lack of correlation between HIV and sexual behavior considered to be unsafe is not rare. There have been many instances of it over the years, in many countries. But few researchers have used the lack of correlation to question the behavioral paradigm. In 2003, a number of researchers published papers suggesting that HIV may not be as closely connected with sexual behavior as HIV prevention programming would lead one to believe. The HIV orthodoxy has yet to refute the body of evidence.

Mapingure and colleagues find that "women in Tanzania reported more risky sexual behaviour than women in Zimbabwe, which is opposite to what is reflected in the HIV prevalence. Prevalence of risky sexual behaviour characteristics, such as having had a casual sexual partner in the previous 12 months, having had more than one lifetime sexual partner, early sexual debut, being in a polygamous relationship and having siblings by different fathers, were all higher for Tanzania. Alcohol consumption, which increases the tendency to engage in risky sexual behaviour, was also more common in Tanzania than in Zimbabwe."

The authors conclude :"Clearly, sexual behaviour only cannot explain the observed differences in HIV prevalence between the two countries" and ask how this "paradox" can be explained. But there is no paradox. They even discuss other papers which make it quite clear that the behavioral paradigm was never in the least bit tenable. Every few years, detailed data on sexual and other behaviors in African countries are found not to correlate with HIV prevalence (check the Demographic and Health Surveys by country).

This paper suggests a few reasons why their results appear paradoxical but the authors seriously consider the possibility that non-sexual HIV transmission might be playing a part in Zimbabwe (which doesn't rule out the possibility of non-sexual transmission playing a part in Tanzania, also). They qualify this possibility by suggesting that such transmission would have been more likely in the 1980s, before the dangers of unsafe medical procedures were widely recognized.

HIV epidemics such as the ones in Zimbabwe, Swaziland, South Africa and others suggest that rates of transmission were probably still high well into the 1990s and perhaps the 2000s. The dangers of nosocomial transmission of HIV, transmission from unsafe medical procedures, may have been recognized a long time ago. But there is little evidence that this form of transmission was successfully eradicated in any sub-Saharan African country. It is more likely that relatively low HIV prevalence in Tanzania is a result of very low access to health services.

Conversely, higher access to health services in Zimbabwe could go a long way towards explaining the incredibly high rates of transmission seen there. And the rates really are incredible. Given the low transmission probability for sexual transmission of HIV per sex-act, Zimbabweans would need to do little else but have sex to explain national prevalence, which reached almost 30% at one time.

In an article commenting on the above paper, Mapingure says "early in the epidemic, syringes weren’t sterilized properly". WHO has recently accepted that as much as 14% of injections are unsafe. Disposable syringes are being reused, either because they are in short supply or because supplies are not reaching their target. Also, health workers are probably not fully trained in making their practices absolutely safe. Published Health Service Provision Assessments make it clear that many Kenyan and Tanzanian health facilities do not have the capacity to eliminate nosocomial infections.

He concludes “Most HIV prevention programmes are failing because they focus on sexual behaviour. We need to look at the whole sexualization of HIV.” This is not just a challenge to the behavioral paradigm. It is a challenge, a long overdue challenge, to the whole of the HIV orthodoxy. UNAIDS and those tasked with reducing the spread of HIV have failed miserably. To this day, they refuse to accept the possibility that non-sexual transmission of HIV is the only thing that can explain the huge differences in prevalence found between and within different countries.