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.

Kenya: Needle Exchange Programs Could Save Lives

[Cross posted from the Don't Get Stuck With HIV blog.]

Despite the success of needle exchange and other harm reduction programs around the world, there people and institutions who still reject them. Even though injection drug use is said to contribute a relatively small proportion of HIV infections in Kenya, apparently some community and religious groups don't always wish to support them. Perhaps they do not understand harm reduction?

Canada has been particularly open to needle exchange and other programs, and the view that "Drug users shouldn’t be given clean needles...it only encourages them" is a minority view now, thankfully. If needle exchange reduces transmission of HIV and hepatitis, it must be encouraged. While it may not cut injection drug use directly, it provides a means of reaching out to users in a meaningful way.

Persecuting durg users and suspected drug users, searching and questioning them, using possession of syringes as a reason for arresting them and confiscating their injecting equipment, do not ultimately result in a reduction in injecting drug use. Worse still, these actions result in users facing potentially more dangerous conditions, as well as increasing syringes and needle reuse.

Community and religious groups may be influenced by a hangover from the Bush era. Bush had a sort of 'victorian' influence; if he believed something, no matter how stupid, his supporters (sort of hard to believe he had them, but he must have) would believe the same thing. This is especially true of his supporters who were in receipt of US funding for their activities.

The contribution of prison populations to the HIV epidemic in Kenya is also said to be high. Even Canada, the US and Australia don't have a needle exchange program in prisons, but it would be wise for Kenya to establish where infections are coming from among prisoners.

Aside from the copious innuendo about what men do in prisons, male to male sex is likely to be an issue in a country where it can land you in prison. Prisoners must face other risks, too. Injection drug use is one possibility, but also perhaps tattoos, body percing, blood oaths, traditional practices occur in prisons? Even sharing razors and other sharp objects carries some risk.

Kenya's Modes of Transmission Survey is not a reliable means of estimating the combined contribution of several groups, such as injection drug users and prison populations. People who fall into these groups may face a high risk of being infected, yet few intervention programs are currently aimed at them.

Needle exchange programs would be a good start and may help to launch other programs, such as opioid replacement therapy, in the long run. But other programs addressing prisoners, men who have sex with men, sex workers and others could address between 20 and 30% of HIV transmission, which is a very substantial figure.

Too many African countries have been swayed by Western prudishness about sexual behavior in their approach to HIV. They have adopted some of the homophobia, xenophobia and other prejudices on which various wars on 'terror', 'drugs' and the like have been based. This has not led to rapid reductions in HIV transmission; so it's time for a change.

[For more about HIV transmission through unsafe healthcare and cosmetic practices, visit the Don't Get Stuck With HIV site.]

The Only Certainty About Unsafe Healthcare and HIV is Ignorance About It

[Cross posted from the Don't Get Stuck With HIV blog.]

An article by Ndebele, Ruzario and Gutsire-Zinyama, who work for the Medical Research Council of Zimbabwe, claims to dismiss the 'wait and wipe' finding, which came from circumcision studies carried out in Africa. This refers to the finding that men who waited at least 10 minutes after coitus and used a dry cloth to wipe their genitals were far less likely to be infected with HIV than both circumcised and uncircumcised men who did not follow this procedure.

What is most extraordinary about this finding is that it has been feebly denied by some, but ignored by far more; in contrast, the findings about a rather weak association between circumcision and HIV transmission was used to push an extremely aggressive, well funded and loudly publicized program to circumcise as many African males, both teenagers and children, as possible.

One should no longer be surprised when researchers embrace the results they expected, while at the same time distancing themselves from those they don't expect, and certainly don't want. The 'wait and wipe' finding was presented at a conference some time back and was covered by US media. But it never received the attention, or subsequent funding, that mass male circumcision programs received.

So, seven years after those hyped mass male circumcision programs started, and a claimed several million men and boys circumcised under the programs, no further research appears to have been done into this interesting finding. Ndebele et al, who don't seem aware that HIV prevalence in Zimbabwe is higher among circumcised men, rebuke several commentators, including myself, for suggesting that 'wait and wipe' could become an alternative strategy to circumcision.

What I said was that appropriate penile hygiene is a lot simpler, cheaper, safer and less invasive than mass male circumcision. The circumcision enthusiasts have encouraged people to associate circumcision with hygiene, but they have never shown that HIV transmission has anything to do with penile (or vaginal) hygiene. It simply suits their purposes that people seem ready to believe in such a connection.

So how can Ndebele et al question the findings about penile hygiene without also questioning those about mass male circumcision? And how can they not call for further research to be carried out? They accuse myself and other commentators of engaging in 'pure speculation', which we do engage in. But we are not the ones who collected the original data, some of which we now wish to selectively dismiss, and the rest of which we wish to use to aggressively promote circumcision programs.

So they proceed to engage in pure speculation of their own, and they seem to believe they are 'dismissing' arguments about the possible role of unsafe healthcare with a rhetorical question: they ask "With all the campaigns on safe needles that have been going on, where on earth can one still find health professionals using unsafe needles?" The answer is that syringe reuse is likely to occur in every high HIV prevalence African country.

Merely running a campaign about unsafe healthcare and syringe reuse does not reveal the extent of HIV transmission through these routes. Nor does running a campaign ensure that unsafe healthcare simply ceases to be an issue after a few years. No number of strategies, position papers, frameworks, roadmaps, multi-page reports, toolboxes or other pen-pushing exercises so beloved by the HIV industry will tell us the extent of non-sexual transmission of HIV through unsafe healthcare.

Nor will 'putting unsafe healthcare on the agenda' (no matter for how long) ensure that any meaningful changes will come about. Most people know little about non-sexually transmitted HIV and are constantly told that 80% of transmission or higher in Africa is a result of unsafe sex. Researchers rarely even mention HIV transmitted through unsafe healthcare, except to dismiss it, without evidence.

The authors argue that the results they wish to embrace are correct and that the results they wish to deny are merely a "coincidental finding", and conclude that "there is no need to conduct further research" into the 'wait and wipe' finding.

This just about sums up the HIV industry's approach to mass male circumcision. This has been a process of scrabbling about for data, any data which appears to support the program, and denying or ignoring any data which shows the program to be a hoax; all cobbled together by greedy (and probably somewhat pathological) 'experts', who will do anything to promote circumcision, ably supported by an institutionally racist HIV industry.

[For more about HIV transmission through unsafe healthcare, cosmetic and traditional practices, see the Don't Get Stuck With HIV website.]

UNAIDS and Uganda: Prejudice Begets Prejudice

Using UNAIDS' inherently flawed Modes of Transmission spreadsheet, the Zambian government have decided that men who have sex with men (along with their assumed female partners) give rise to 1.4% of new HIV cases every year. Not a high percentage. But even African countries which use alternative means of estimating also come up with a relatively low figure.

Despite the fact that the contribution is known to be low, some don't seem to be able to resist the temptation to whip out the homophobia card at every opportunity. The current anti-gay frenzy in Uganda may have been stirred up by various conservative evangelical Christian groups, but it has become a useful political tool; whenever anyone mentions anything political, someone starts spewing out homophobic bilge. What are purely homophobic attacks are then dressed up as part of an anti-HIV strategy.

Spurious figures from UNAIDS for the proportion of HIV transmission said to be a result of some kind of illicit sexual behavior are used to support an assumption that anyone with HIV has engaged in illicit sex. Therefore, even though the contribution of men who have sex with men is not high, it's an easy step to just point the finger at any group you hate, or whose behavior you consider to be wrong (or 'sinful'), and blame them.

But the Ugandan government has tried to claim that its homophobic act (the Anti-Homosexuality act of 2014) does not put healthcare employees in the position where they must choose between running the risk of accusations of 'promoting the act of homosexuality' or 'abetting homosexuality' and the like, which carry a heavy sentence, or breaching their ethical and professional codes of conduct (and international human rights agreements). The government's "Ministerial Directive on Access to Health Services without Discrimination" does not explain how healthcare workers should resolve this dilemma.

The trumped up nonsense about gay people 'recruiting' youth is reminiscent of other rabid conservative fundamentalist claptrap that has fed the media for decades. But the 'blame the victim' mentality and the finger pointing at assumed sexual behavior of African people in the field of HIV comes directly from UNAIDS and the HIV industry. There's a gem of wisdom from their former Chief Scientist on this blog post, but it's pure redneck, so prepare to be offended.

The best way to defuse this obsession with linking HIV to things various atavistic parties consider evil, such as male to male sex, or sex between African people (and between African Americans), is to trace the non-sexual as well as the sexual contacts of people testing positive. It will then become clear that the virus can also be transmitted through unsafe healthcare, cosmetic and traditional practices, and not just through unsafe sexual behavior.

Denial Reigns Supreme in the HIV Industry

[Cross posted from the Don't Get Stuck With HIV blog.]

Just a couple of days ago I mentioned the industry myth that everyone is at risk of being infected with HIV, but I didn't expect to come across this piece of 1980s PR again so soon. Nor did I expect to find it in the New Republic.

Most disturbingly, the article is about "interactive maps depicting where AIDS infections were most prevalent [in the US]". These maps corroborate what statistics have shown for a long time, that the people most likely to be infected live in certain identifiable places, that the epidemic is often associated with poverty, and that black people are far more likely to be infected than white people.

I find this disturbing because, having depicted so clearly that people living in certain parts of the country where the population is either poor, black or both are far more likely to be infected, the lead researcher is quoted as saying that "the fundamental, scientific truth of HIV hasn’t changed. Anybody can still get it."

This is not a 'scientific truth', nor any other kind of truth. It was realized a long time ago that many powerful people would not support a program to address a disease that was said to be prevalent mainly among men who have sex with men and injection drug users. So campaigns were based on spurious 'expert opinions', and data was massaged to suggest that everyone was at risk.

Fair enough, in the US it may have seemed at the time that men who have sex with men and injection drug users were already discriminated against, and this prejudice would need to be addressed before much progress could be made against the recently discovered virus. The campaigns were supposed to take the heat off these (at that time) marginalized groups.

It probably worked in the case of men who have sex with men, although it wasn't so successful for those who inject drugs. But one of the biggest fallouts from the campaign was the effect it had on what became the received view of HIV in African countries, some of which still had very low prevalence at the time, but would eventually suffer the worst epidemics in the world.

The HIV industry was built around the promulgation of the view that if HIV prevalence was highest among people who only engaged in heterosexual sex, as it was found to be in high prevalence African countries, they must have engaged in massive amounts of sex, and it must be very unsafe sex.

But even after the industry abandoned its claim about everyone being at risk, they didn't abandon the myth that most HIV transmission in African countries is a result of unsafe heterosexual sex. As a result, three decades of unsafe healthcare has almost entirely escaped the attention of the industry, along with the billions thrown at the virus.

Some in the industry still pontificate about more women than men being infected in African countries, the fact that babies are still being infected despite scaling up of antiretroviral drugs, high death rates despite the amount of money spent on treatment, etc, but none of them have asked about non sexual risks, through unsafe healthcare, cosmetic and traditional practices.

It was OK to talk about non-sexual transmission in the early days, and it's still OK to talk about it when children are infected (and, on rare occasions, white, middle-class heterosexuals in Western countries, presumably). So why is it difficult to accept that adults in African countries, even adults who are sexually active, can also face non sexual risks?

Groups of people said to be at higher risk of infection in African countries were identified left, right and center, but none of them were identified for their non sexual risks, only for their assumed sexual risks. Almost all women (of course), 'mobile' people (not just transport workers, but also migrant workers, soldiers and many others), those engaged in certain occupations, such as fishing and mining, etc.

But women who are sexually active tend to visit health facilities, sex workers visit sexually transmitted infection clinics, so do soldiers and transport workers (and others), big employers such as mines often provide some kind of rudimentary health services, as do some government departments; healthcare is not as ubiquitous as sex, but it is pretty widespread in certain places.

Those who were not at risk, in contrast, often seemed to be poorer people, uneducated people, rural dwelling people, people who didn't live very close to infrastructure or health services, unemployed people and others, whose low risk is explained away by rubbish about smaller sexual networks and the like.

The myth about everyone being at risk of HIV is dangerous because it is so closely related to the myth that HIV is almost always transmitted sexually in African countries. If people don't know the non sexual risks, they will not know that they need to avoid them, or how to avoid them; if risky practices in health, cosmetic and other facilities are not addressed, they will continue to occur.

[For more about HIV infection through unsafe healthcare, cosmetic and traditional procedures, see the Don't Get Stuck With HIV website.]

Philippines: It’s All About Sex, Even When it Isn’t

[Cross posted from the Don't Get Stuck With HIV blog.]

An official at the Department of Health in the Philippines has called for "the public with risky sexual behaviors to undergo HIV testing". This is said to be due to UNAIDS' 'Global AIDS Report', which claims that the country is one of nine where cases of HIV "rapidly increased by 35% in the last 10 years, from 2001 to 2011.

While it is true that the number of people estimated to be living with HIV in the country has gone from about 5,000 in 2001 to about 15,000 in a decade, this is in a country of almost 100,000,000 people. Prevalence is estimated at 0.1%. Also, what the report I have (from 2013) underlines is an increase in infections among injection drug users, no mention of sex (for a change).

The article concludes that "HIV infection is transmitted through sexual intercourse, by blood transfusion and from an infected mother to her child". But this is not helpful to those who may have been infected as a result of unsafe healthcare, traditional or cosmetic skin-piercing procedures.

Luckily for the Philippines Department of Health, in 2007 a team of people carried out and published an "Assessment Survey of Injection Safety and Safety of Phlebotomies, Lancet Procedures, Intravenous Injections and Infusions in Government Health Facilities in the Philippines", using a survey developed by the WHO (Tool C).

The survey found, among other thngs, that "the frequency of re-use of needles and evidence for attempts to sterilize used needles was low (less than 16%)". Given the billions of injections administered every year around the world, I wouldn't consider 16% to be low, but we'll allow them their opinion.

The survey also noted "High frequency of noncompliance to best injection safety practices are widespread in the government facilities including...use of multidose vials with needles left neglected onto the diaphragms", "High frequency of high risk practices prone to needle stick injuries", a widespread lack of adequate sharp disposal systems, incomplete protection for hepatitis B and that "Almost all facilities were unable to show a manual of injection safety or a manual of waste management".

Unluckily, UNAIDS is not going to take any notice of such a report because, even though the Philippines is not in Africa, where it is claimed that almost all inections with HIV are a result of sexual behavior, the institution can not accept that unsafe healthcare plays any role whatsoever in HIV transmission in poor countries, with understaffed, under-equipped and overcrowded health facilities.

[For more about HIV infection through unsafe healthcare, cosmetic and traditional procedures, see the Don't Get Stuck With HIV website.]

Foundation Myths: Why Tracing HIV Infections is Anathema to HIV Industry

[Cross posted from the Don't Get Stuck With HIV blog.]

A short article about HIV from the British Medical Journal, written in 1992 (pre-UNAIDS) sheds some light on an early piece of HIV myth-making. Though over 20 years old, the article has a very recent feel to it. Apparently someone at the time predicted that "by the year 2000, 90% of HIV infections would be acquired through heterosexual intercourse".

UNAIDS, in all its extravagance, currently claims that 80% (sometimes 80-90%) of HIV transmissions are a result of heterosexual sex. The 1992 article also goes through the same illogical contortions that UNAIDS now specializes in: "At an antenatal clinic in Kigali, Rwanda, no less than a quarter of women with only one lifetime partner had been infected with HIV, presumably by their steady partner."

It probably wasn't yet clear in 1992 that HIV prevalence among those receiving antenatal care (ANC) were not representative of the population as a whole. Even if 'a quarter' of women were infected, it was shown later that nowhere near that proportion of men were infected; also, prevalence in Kigali, being a city, is far higher than in the country as a whole.

The paragraph begins by talking about risk, before going on to women who only have one lifetime partner; hence the 'presumption' that it is the men who take the risk and then infect their wives/partners. These twin assumptions, that in Africa HIV is almost always transmtted through sex and that it is almost always men who 'spread' the virus, became the backbone of UNAIDS and HIV industry dogma, and remain so to this day.

Enough is now known about transmission rates to suggest that 25% of ANC patients were not infected through heterosexual sex, that many of them, perhaps all of them, were infected through some other route. Perhaps the women even went on to infect their partners, rather than the other way around.

But UNAIDS now has a rigorously flawed model to 'prove' that most of the people 'at risk' of being infected through heterosexual sex (ie, most people in high prevalence African countries) do not engage in risky behavior at all. Some of the flaws are highlighted in a post that appeared on this blog recently.

At some early stage in the history of HIV it became anathema to talk about how someone may have become infected with HIV in Western countries, and the industry came up with the myth that everyone was at risk, something many people still believe. However, it was well recognized by those working with HIV that few people were at risk unless they were men who had sex with men or injecting drug users.

But we are not supposed to say that. It was quickly established that HIV positive people in African countries were not very often men who had sex with men (even then there were more women infected than men) or people who injected drugs. So it was hypothesized, on the basis of no evidence to support and plenty to contest, that heterosexual sex must be responsible for the bulk of transmissions.

Continuing a long tradition of blaming the victims in developing countries, and refusing to investigate unsafe healthcare, (peer-reviewed) paper after paper begins with the unquestioned assumption that almost all HIV transmission in African countries results from heterosexual sex. But we wouldn't want to stigmatize people; so we don't attempt to trace their infections, dear me no.

[For more about HIV risks from healthcare, cosmetic and traditional procedures, visit the Don't Get Stuck With HIV website and blog.]

South Africa: With This Kind of Research, Who Needs Ignorance?

[Cross posted from Don't Get Stuck With HIV website and blog.]

Following a recent article about HIV among 'old' people in Tanzania which I discussed a short while back, another article has appeared about an increase in HIV among people over 50, this time from Gauteng, South Africa. Prevalence in Gauteng is high, though it is not the highest in the country. The article concentrates, as is customary for articles about HIV, on sexually transmitted HIV, noting 'unsafe' sexual behavior, in addition to 'caring for infected children'.

However the apparent lack of concern older people are said to feel about being infected, along with their 'ignorance' which the authors note, may stem from the fact that people in this age group do not engage in as much 'unsafe' sex as imagined, that the sex they engage in may not be as 'unsafe' as imagined, and that they may face many non-sexual risks as a result of not being informed about these; constant emphasis of sexual transmission and under-emphasis of non-sexual transmission doesn't help either.

Are the researchers even aware that every skin piercing procedure could be a risk, not just reused injecting and other equipment, but also reused cosmetic instruments (tattooing, piercing, shaving) and reused instruments in traditional practices (traditional medicine, scarification, circumcision)? If older people do not, as the authors suggest, see themselves as being at risk of being infected with HIV, perhaps this is because the non-sexual risks they face through caring for HIV positive people, and risks they face themselves in healthcare, cosmetic and other facilities, have rarely been addressed by HIV intervention programs.

The most worrying aspect of this paper is that it is assumed that sex is the only, or the biggest risk, for HIV. This means that non-sexual risks, which may increase in older people who may have greater healthcare needs, are given so little attention that people do things which they don't even realize are a risk. Worse still, those providing healthcare, cosmetic and traditional procedures may not realize the risks, or they may be a lot less vigilant in their day to day activities.

Despite the emphasis the authors put on sexual transmission, "using the same needles or sharp objects" was mentioned by at least one of the interviewees. Also, two traditional healers were among those interviewed and seemed aware of their risk to themselves, but not the risk that their clients face, which may be a lot higher. But the use of 'protective clothing' by those caring for HIV positive people is far too vague to be of any practical value. What about mentioning skin piercing procedures, needlestick injuries, reuse of needles, syringes, razors and other skin piercing instruments?

This seems to be another missed opportunity to address the substantial non-sexual risks people face from infection with HIV and other bloodborne diseases through skin piercing procedures, whether carried out for medical, cosmetic or traditional reasons. Older people, the subject of this paper, and others around them, may face increased risks from skin piercing procedures, especially those found in health facilities. Instead, the authors obsess about the purported sexual behavior of South African people and fail to make any recommendations about reducing non-sexual HIV transmission.

[For more about non-sexually transmitted HIV through unsafe healthcare, cosmetic and traditional practices and how to protect yourself, visit the Don't Get Stuck With HIV site.]

More junk science underestimating HIV from medical injections

[Cross posted from the Don't Get Stuck With HIV blog - for more about HIV infection through unsafe healthcare and cosmetic practices and how to protect yourself, visit the site.]

AIDS experts still haven’t figured out what is different about Africa that can explain why HIV epidemics there are so much worse than elsewhere. The continuing failure to find what is different about Africa’s epidemics exposes persistent (intentional or natural) incompetence on the part of respected researchers.

Specifically, scores of studies that have tested, followed, and retested hundreds of thousands of HIV-negative Africans to find when and how they get HIV have failed to trace the source of observed new infections.[1] Without tracing the source, there is no way to say infections came from sex – but “HIV from sex” is nevertheless the conclusion (and racist slur) from decades of incompetent, incomplete research. When such studies find people with new HIV infections who report no possible sexual exposure to HIV, researchers characteristically reject the evidence: “hmmmm, an African with HIV…must have lied about sexual behavior….”

With that “scientific” method, the US National Institutes of Health and UK’s Medical Research Council could save money by paying researchers sitting in offices in Baltimore, US, or Oxford, UK, to make up data to fit pre-determined conclusions. That would be more efficient than paying them to go to Africa, collect data, and then reject what doesn’t fit desired conclusions.

While funders have avoided funding good science to explain Africa’s HIV epidemics – for 30 years and counting – they have been all too happy to fund junk science that will get the desired results. One popular junk-science strategy to get desired results has been to model Africa’s HIV epidemic with unreliable parameters and weak, selected, or made-up data.

The latest paper by Pepin and colleagues[2] falls into that category of junk science – presenting a model with unreliable parameters and data, and using results from the model to claim that unsafe medical injections accounted for less than 1% of new HIV infections in Africa in 2010 (8,000-16,000 from injections vs. 1.9 million total new infections[3]).

Several obvious problems with the estimate are as follows:

1. Pepin’s assumed rate of HIV transmission through a contaminated syringe or needle – 1 in 150-300 injections – is far too low to allow observed HIV outbreaks through health care in Russia, Romania, Libya, and elsewhere. If those outbreaks occurred – they did! – then Pepin’s proposed rate of HIV transmission through injections is misleadingly low. For example, in Russia in 1988-89 hospital procedures passed from HIV from 1 child to more than 260 children in 15 months. Most transmissions in this outbreak came from children who had been infected less than 6 weeks earlier – enough time for infected children to get dozens but not 150-300 skin-piercing procedures followed by reuse of unsterilized instruments.[4]

2. Pepin’s same model estimates 4,300-8,500 new hepatitis C virus (HCV) infections in Africa from unsafe injections in 2010, less than 1% of estimated new HCV infections (cf: an estimated 18 million Africans were living with HCV in 2005[5], which corresponds to approximately 1 million new infections per year). Because virtually all new HCV infections come from blood, not sex, it’s likely that unsafe injections account for a lot more than 1% of new HCV infections – and by extension, more than 1% of new HIV infections as well. Furthermore, other skin-piercing procedures aside from injections likely account for a lot of new HCV infections – and by extension a lot of new HIV infections as well.

3. Pepin’s estimates distract from facts that need answers. Why do 16%-31% of HIV-positive children in Mozambique, Swaziland, and Uganda, have HIV-negative mothers (among children with tested mothers)?[6] Why do so many mutually monogamous couples find that one or both partners are HIV-positive?

In his conclusion, Pepin commendably recognizes “other modes of iatrogenic transmission” including[2]: “use of multi-dose medication vials, phlebotomies with re-used needles, dental care with improper sterilisation of instruments, unscreened transfusions, ritual scarifications and circumcisions performed by traditional practitioners… Better measurement of such exposures and of their impact on viral dynamics is an essential first step…”

Even so, Pepin does not hit the nail on the head. What is required to measure the “impact [of such procedures] on viral dynamics” is to trace HIV infections to their source. When infections are traced a hospital, dental clinic, tattooist, etc, then continue with outbreak investigations to determine the extent of the damage from unsafe health care or other skin-piercing procedure.

References

1. Gisselquist. Randomized controlled trials for HIV/AIDS prevention in Africa: Untraced infections, unasked questions, and unreported data. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 14 June 2014).

2. Pepin et al. Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010. PLOS one 2014; 9: 1-8. Available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0099677 (accessed 14 June 2014).

3. Annex table 9 in: UNAIDS. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access, progress report 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241502986_eng.pdf?ua=1 (accessed 15 June 2014).

4. See: http://dontgetstuck.org/russia-cases-and-investigations/

5. Hanafiah et al. Global epidemiology of hepatitis C virus infection. Hepatitis 2013. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hep.26141/pdf (accessed 14 June 2014).

6. See pages for Mozambique, Swaziland, and Uganda at: http://dontgetstuck.org/cases-unexpected-hiv-infections/; see also: http://dontgetstuck.wordpress.com/cases-unexpected-hiv-infections/).

Sexually Transmitted Infections Can Also Be Spread By Unsafe Healthcare

When patients are found to have been exposed to HIV or other viruses as a result of the care they received, so called 'nosocomial' infections, they are usually recalled for testing and treatment, as required. This certainly happens in many rich countries, but not always, it seems.

A doctor operating in Philadelphia illegally aborted fetuses in their third trimester and then killed them by severing their spinal cords with scissors. Many women have been seriously injured as a result of this doctor's treatment and some have died.

The doctor has been convicted of murder and the fact that so many people were affected over such a long period of time has been put down to a 'complete regulatory collapse'. The case is so horrifying that it is probably difficult for those reading about it to concentrate on anything but what should happen to the perpetrators and how this sort of thing can be prevented from happening again.

But what about all the women who have been treated in the appalling conditions described in the article? They have been exposed to all sorts of things, some of which will make them very sick, some of which will eventually kill them. They need to be screened and treated, if it's not already too late.

The issue is not just how authorities should have done their job in the first place, that's the concern of relevant institutions and regulatory bodies. But for the women concerned, their immediate need is for proper health care, albeit belated. Lives may be saved, illness averted and even mental trauma may be relieved.

Other articles I have seen involving unsafe healthcare mentioned the actions that were taken to limit the damage to those who were still alive. But I have yet to find out if all previous patients have been traced in this instance. Is this because no effort has yet been made to trace them, or is it that the sheer horror of the case has distracted attention from the victims?

A number of other employees in the same clinic were also indicted with various crimes and the clinic, which appears to have concentrated on late term abortions, was operating for 16 years. There is no telling what risks the patients faced over the years.

The circumstances surrounding the case are almost beyond belief and my question is not about the fact that so many warning signs were ignored for so long; rather, I'd like to know if it is true that most of the clientele attending this clinic were poor and/or non-white.

The chances of non-white, especially black, Americans becoming infected with HIV are far higher than the chances of white people becoming infected. Similar remarks apply to sexually transmitted infections (STI). But high prevalence of STIs doesn't merely indicate high levels of unsafe sexual behaivor. It could also indicate low levels of health care provision, especially sexual and reproductive health care.

The jury in the case of the clinic doctor, Dr. Kermit Gosnell, concluded: "Bureaucratic inertia is not exactly news. We understand that. But we think this was something more. We think the reason no one acted is because the women in question were poor and of color, because the victims were infants without identities, and because the subject was the political subject of abortion." And apparently white clients were treated quite differently.

Many women who attended this clinic were infected nosocomially with sexually transmitted infections. Being sexually active, poor and non-white, it would probably have been assumed that they were infected sexually. Nosocomial infection appears to be of interest in other cases of unsafe healthcare, but not in this one. Not so far, anyhow.

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.

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.

After Decades of Torpor, Is WHO Waking Up to the Problem of Unsafe Injections?

Recently, I wrote about condom manufacturers' apparent lack of concern that their products seem to get such bad press where clinical trials of HIV related medicines are concerned. I also linked to an article about a group of Nigerians  taking their government and various other state and non-state institutions to court because they used condoms correctly and consistently but still became infected with HIV. Several non-Nigerian institutions are also involved, including Family Health International (FHI).

Granted, numerous institutions have conspired to blame HIV transmission in Africa almost entirely on sexual behavior, when this is clearly not the whole story. But plaintiffs argue that they were used to test the efficiency of a particular brand of condoms, which were substandard. Perhaps there is evidence that this particular brand of condoms was faulty, in which case, they should indeed be withdrawn.

But the plaintiffs appear to want all condoms to be withdrawn from the market. It would be very surprising of it turned out that all condoms were faulty, despite the claims of the Catholic and other churches that this is so. There is plenty of evidence that condoms are effective in preventing the transmission of HIV and various other sexually transmitted infections. Condoms remain the most effective protection against sexual transmission of HIV.

What condoms don't do is protect people from non-sexual HIV transmission. This may sound too obvious a point to make, but there have been constant claims that abstaining from sex, only having sex with one, faithful partner and using condoms, are the only strategies for avoiding HIV transmission. Worse still, some claim that abstinence from sex is the only way. None of these claims are true.

Abstaining, being faithful and even using condoms will only protect from sexual transmission of HIV. They will not protect from non-sexual transmission, such as through intravenous drug use, unsafe medical practices or unsafe cosmetic practices.

Rather than admitting that they are wrong, the HIV hierarchy also claim that non-sexual HIV transmission is very rare in African countries. Such transmission happens in other countries, poor Asian countries, rich Western countries, Eastern European countries and everywhere else. But, it is claimed, it is too rare in African countries to merit more than about 1% of prevention funding. Never mind that health services range from appalling to non-existent in most African countries.

The WHO is relatively unenlightened when it comes to admitting that HIV prevention strategies are in need of review, given their almost total lack of success over the past few decades. But they do accept that unsafe injections are extremely common. Syringes and other injecting equipment are unsafe because single use equipment are being reused, without adequate (or perhaps any) sterilization.

According to the WHO, "in Africa alone, 20 million medical injections contaminated with blood from patients with HIV are administered every year". How they can also estimate that this results in only 23,000 HIV infections (also, a million hepatitis C and 21 million hepatitis B infections) every year is a mystery, given the efficiency of HIV infection through reused injecting equipment. But it gives an indication of the scale of the problem.

Apparently there is a campaign in Tanzania to have all single use injection equipment phased out and replaced with 'auto-disable' equipment, which breaks after use and therefore can't be reused. The sooner the better.

However, Tanzania's problem is not just with single use injection equipment being reused. They also have too few medical facilities, too few trained healthcare staff, too little equipment and various other things. It remains to be seen if the introduction of auto-disable syringes will be accompanied by improvements in supplies and all the other lacks. After all, there must be some reason why the health and lives of so many people are being put at risk for want of cheap equipment.

The Nigerian case is somewhat different because it appears to claim that a particular brand of condoms do not adequately protect against HIV infection. But the WHO findings, which probably seriously underestimate the problem, make it quite clear that sex alone is not responsible for HIV transmission in countries with sub-standard health services. Therefore, HIV prevention strategies should be extended to include the prevention of non-sexually transmitted HIV, especially nosocomial infections, those occurring in hospitals as a result of medical treatment.

[If you are interested in the question of whether people will be prepared to combine strategies, such as male circumcision, mcirobicides and pre-exposure prophylaxis with continued condom use, see my other blog.]