Cambodia, Unsafe Healthcare, Injections: Time for a Changing of the Guard?

There's a very succinct set of photographs by Marc Koska of the SafePoint Trust about the HIV outbreak in Cambodia's Roka Commune. Over 270 people are said to have tested positive so far, several of whom have already died. Unsafe healthcare is thought to have been behind this outbreak, reuse of syringes and other skin piercing equipment by medical practitioners who do not have the knowledge, skills or equipment to avoid such occurrences.

Koska invented an auto-disable syringe many years ago, a syringe that breaks if you try to reuse it, but he has been lobbying health and HIV institutions to promote the use of this simple and cheap technology ever since.

It is highly unusual for the BBC to express the slightest hint of disagreement with the mainstream view of UNAIDS and other institutions, that HIV is almost always transmitted through unsafe sex, and hardly ever through unsafe healthcare. Perhaps because this outbreak was in Cambodia, where HIV prevalence is low, this story flew under the radar.

Sadly, as the article points out, use of auto-disable syringes is too late for those already infected, but it is not too late for other Cambodians, nor for HIV negative people living in countries where HIV and other blood-borne viruses are common and, more importantly, where safe healthcare is uncommon.

UNAIDS and others in the HIV industry have been ranting on about 'unsafe sex' and completely avoiding the issue of unsafe healthcare, even denying its possible role in the most serious HIV epidemics in the world, which are all in Africa. Perhaps this will bring various kinds of unsafe healthcare into focus, however belatedly.

Cambodia is not the only Asian country where unlicensed practitioners operate; and even licensed practitioners may reuse needles, syringes and other skin-piercing equipment. The practitioner who has so far been the only scapegoat is unlikely to be the only person to practice healthcare unsafely. The investigation should be global, not confined to a population of a few thousand.

As for African countries, it should be clearer than ever that unsafe healthcare must no longer be denied by UNAIDS and other health agencies as an important mode of transmission of HIV and other viruses in African countries. People shouldn't have to be Buddhist monks, very young or very old to be believed when they say they have not engaged in 'unsafe' sex, or any sex at all.

The UNAIDS view that HIV is almost always transmitted through 'unsafe' sex and hardly ever through unsafe healthcare is vehemently expressed in a BBC article from 2003, and these views don't appear to have changed since (although the UNAIDS official in question, along with some of her senior colleagues have since availed themselves of the revolving door).

The maliciously racist view of Africans that the senior UNAIDS official is, apparently, allowed to make public, doesn't seem to have changed either.

It's also worth bearing in mind that UNAIDS are well aware of the risks of healthcare transmitted HIV and other infections in developing countries. They publish a brochure warning UN employees not to use health facilities in such countries; this contrasts very strongly with what the BBC published the year before. Perhaps now they UNAIDS will promote this in Cambodia, and hopefully in Africa too?

Circumcision: Digital Manipulation May Lead to Reduced Vision

Following my previous post, I’ve put together some of the data available on HIV and circumcision on this site, along with some additional data, in order to emphasize a few points.

Convincing arguments have been made to show that there is no overall benefit found when comparing HIV prevalence among circumcised and intact men in a number of countries for which figures are available; prevalence is higher among circumcised people in some instances and higher among intact people in others.

This raises the question of whether circumcision, or perhaps circumcision on its own, might be irrelevant to heterogeneity among HIV epidemics. After all, there are other differences, aside from circumcision status, between the populations of various countries for which figures are available.

Here’s an example: there's a group of seven countries which were formerly colonized by Belgians, French and Portuguese (or remained uncolonized) for which circumcision/HIV related information is available. With the exception of Mozambique, the former Portuguese colony, HIV prevalence in the others is low to medium. The total number of HIV positive people in these countries is estimated at just under four million.

[Table available on Don't Get Stuck With HIV site]

But there's another group of nine countries which were formerly colonized by the British. Although prevalence is low in one of them, located in lower prevalence West Africa, the others are all high to very high prevalence countries, coming to a total of just over nine million HIV positive people. Indeed, about 80% of all HIV positive Africans reside in former British colonies, which comprise more than half the population of Africa.

[Table available on Don't Get Stuck With HIV site]

Undeniably, HIV prevalence and circumcision do show a very strong North/South divide. Most men (and many women) in northern African countries practice some form of genital alteration, known as circumcision when applied to men, and HIV prevalence is very low in these countries. In contrast, circumcision is not predominant in most of the highest prevalence countries in southern Africa.

There are fewer than 150,000 HIV positive people in Egypt, Libya, Algeria, Niger, Mauritania, Tunisia, and Morocco combined, these countries comprising almost 20% of the population of Africa. But I would argue that the northern countries did not 'successfully fight off' HIV, as is sometimes suggested. In fact, the virus didn't arrive in the region until the mid-80s, more than three decades after it established itself in eastern Africa.

There are sex workers, men who have sex with men, intravenous drug users, clients and partners of these groups in northern African countries, just as there are in all other countries in Africa (and the rest of the world). The enormous Sahara Desert may have shielded northern African countries to some extent from the spreading virus, but prevalence is not low there because ‘unsafe’ sex is less common than in southern countries.

Southern and eastern African countries are almost all former British colonies, whereas only a handful of former British colonies can be found in Equatorial, western or northern Africa. Of course, the British colonials didn't spread a virus they still hadn't heard of, nor did the non-British colonials avoid spreading it.

Rather, the colonials developed the structures that allowed the virus to spread, with varying levels of efficiency; the roads, railways and ports, the overcrowded cities, the oversubscribed health facilities, the industrial outlets, especially extractive industries, the huge pools of labor, living in squalor away from their families, etc.

So, the influence of certain types of administration on determinants of health (and disease) may be behind much of the heterogeneity found HIV epidemics in African countries. But there is nothing to lead one to the conclusion that circumcision status, or even sexual behaviour, are clearly linked to HIV prevalence.

If you start out believing that HIV is almost entirely transmitted through 'unsafe' sexual behavior, and that circumcision gives some level of 'protection' against HIV transmission, some of the figures bandied about might persuade you that it's a good idea to spend billions aggressively recruiting as many men as possible to be circumcised; but that's all down to your preconceived views.

CDC on Circumcision: Just Lie, No One Will Notice!

Professor Robert van Howe was requested, in his capacity as a pediatrician with an expertise in male circumcision, to peer-review the US Centers for Disease Control and Prevention's (CDC) draft recommendations following their 'Consultation on Public Health Issues Regarding Male Circumcision in the United States for the Prevention of HIV Infection and Other Health Consequences'. The full peer-review is available on the Academia.edu site, with some comments and a brief extract on the Circumcision Information website.

One might think, from the constant bombardment of articles in praise of circumcision, that there was a fair body of thought in favor, and a comparable body of thought against the practice. However, the majority of countries in the world do not practice routine male circumcision for 'medical' purposes, and only a minority do so for religious and/or cultural reasons. Enthusiasm for the operation for 'medical' reasons emanates almost entirely from the US.

Van Howe's critique is not technically difficult, and many of the arguments against male circumcision would be widely accepted, perhaps even by those who have little familiarity with the subject. But the list of criticizms of the CDC's draft runs to over 100 pages, with the bibliography of literature supporting the case against the operation running into another 100 pages.

The CDC draft is found to lack scientific and scholarly rigor, neglecting important and relevant findings, but using reviews and other lower quality material instead. Research was carried out carelessly and reported badly. Grasp of basic epidemiology among those who wrote the draft is also low. Van Howe suggests that these apparent flaws may have been part of a deliberate attempt to bias the subsequent recommendations.

In addition to highly selective analysis of medical evidence, ignoring any that might not support what seem like CDC's prior belief in the virtues of male circumcision, the authors continue a long tradition among proponents of the operation of failing to discuss any kind of causal mechanism by which it might 'prevent' HIV or various sexually transmitted infections (STI).

While US professional medical associations resolutely stand by their long held regard for circumcision, equivalent associations elsewhere continue to express their opposition to it. The CDC's draft neglects to mention any of this substantial opposition by experts. Yet the intention of the CDC's recommendations are that they will form the basis of advice and information to be given by medical professionals to members of the public about the operation.

Van Howe's recommendation is that this draft be scrapped and the process be started again, from scratch. He also advises that they " review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa."

But what's this about Africa? Van Howe finds that much of the 'evidence' for the claimed benefits of circumcision in 'reducing' transmission of HIV and other STIs comes from studies carried out in African countries, despite being used to support their arguments that it should be routine in the US. These often-cited studies carried out in Africa are themselves highly questionable, were carried out by people who were already convinced that circumcision 'reduced' HIV transmission, and have spent many years (and many millions of research dollars) trying to push their agenda in African countries (with varying levels of success).

The US is by no means the lowest HIV prevalence country in the world. In fact, it has the highest prevalence among wealthy countries, despite spending a lot more per head on health than some others. The largest HIV positive population in the western world can be found in the US, even though there are probably more men there who were circumcised for 'medical' reasons than in any other country.

Van Howe's article may come closer to listing every major argument against male circumcision as a 'medical' intervention against HIV and STIs than any other; it certainly provides counter-arguments against the sort that the CDC draft seems to be filled, flimsy, half baked maunderings and puerile innuendo, apparently the best that many years of study by a whole team of researchers can muster. Even if you can't read the entire peer-review it will be a good source of information, with a very comprehensive bibliography.

The CDC must be a very powerful part of American democracy if they can spend so much effort and money lying to the public about male circumcision. The operation has been entirely discredited as an intervention for reducing HIV and STI transmission, even in African countries that have far more serious HIV epidemics than the one in the US. But it's difficult to imagine why this lie is supported by so many US professionals, academics, institutions and money.

Blinded by Bigotry: Why Researchers May Have Been the Only Ones Surprised by VOICE Trial Failure

The failure of the VOICE pre-exposure prophylaxis trial, daily treatment of HIV negative people with antiretroviral drugs via a vaginal gel, was guaranteed by the long and widely held assumption that almost all HIV transmission in African countries is a result of 'unsafe' sexual behavior.

Participants were deemed to be at risk of being infected with HIV by researchers who had no evidence for this risk. In fact, sexual risk was low, with only one fifth reporting more than one sex partner in the previous three months, low rates of sexual intercourse, very high rates of condom use and fairly low rates of anal sex (which may or may not have involved condoms).

During this trial HIV incidence was very high, 5.7 cases per 100 person years, although it went as high as 9.9 per 100 person years in Durban, a figure that is in urgent need of investigation. Yet, researchers made no effort to find out how the several hundred seroconverting women were infected. There were high rates of certain sexually transmitted infections (though low rates of others); could some women have been infected with HIV as a result of unsafe treatment at an STI clinic?

A whopping 71% of the participants use injectible Depo-provera (DMPA), which is known to significantly increase HIV transmission risk from women to men and from men to women. Two thirds of participants were from Durban, in South Africa's highest prevalence province, Kwa-Zulu Natal. To what extent could this have contributed to these high HIV transmission levels?

It is to be wondered if taking part in this trial could have exposed many women to the risk of being infected with HIV, given that they were selected on the basis that they were currently uninfected and had low sexual risk at baseline.

Whatever the answer to these questions, the unwarranted but ubiquitous assumption that HIV is almost always transmitted through heterosexual intercourse in African countries (but not elsewhere) remains in urgent need of revision. But where does it come from?

UNAIDS, effectively a UN funded lobby for the rich and powerful pharmaceutical industry, bandies the figure about at every opportunity. The claim had been made before this lobby was spawned, but it seems impossible now to identify any body of evidence to support it. Indeed, evidence claimed to support it often suggests the opposite, such as the baseline figures collected by the VOICE study.

Until the HIV industry establish how people are being infected with HIV and employ appropriate (and effective) prevention interventions, high rates of transmission will not stop in African countries. The continued recruitment of vulnerable people in high HIV prevalence areas for trials adminsitrated by researchers who are so entirely blinded by bigotry is inexcusable.

To make matters worse, some are calling for types of monitoring that no longer require them to rely on answers given by participants themselves. This is yet another instance of a 'veterinarian' approach to Africans, similar to the insistence on the utility of injectable Depo-provera (DMPA) in developing countries, despite evidence of harm that even those promoting the drug do not deny.

There is a supremely patronizing article on the trial in the New York Times which, like the researchers, can't accept the possibility that it failed for any other reason than the "elaborate deceptions employed by the women in it". Nothing is said about the elaborate deception of the HIV industry and the researchers eagerly looking for any way of giving pharmaceutical companies the green light to sell ever growing quantities of their grossly overpriced products.

Instead of admitting to any of their obvious failures, researchers are finding ways to get around trial conditions specifically designed to ensure that such trials do not depend entirely on lies and subterfuge in their efforts to find positive results for the various sub-sectors of the HIV industry that stand to benefit most.

Viewed from a different angle, the many rumors that the NY Times article refers to are not surprising, given the experiences of African people countries of unethical practices, harmful procedures, fudged figures for adverse events (or a failure to report them), outright lies told to participants and cover-ups of evident harm to people taking part in trials, and even to people taking various medications.

The issue of payments to participants is briefly discussed (after all, if there's sex there must also be money, right?). One 'global health specialist' says “I’ve never been concerned that money is the factor driving participation or is corrupting the results”. He may like to revise that view during future trials, rather than by further eroding the already weak protection from abuse that participants currently receive.

When a trial fails as miserably as the VOICE trial, researchers need to re-examine some of their most unsupported assumptions, particularly their most bigoted ones. Then they might think twice (or even once) before accusing participants of deception, in addition to promiscuity, lack of understanding, and indifference to the risk of transmitting a deadly disease to their partner and their children.

HIV and Funerals in Kenya: Just add 'Culture' and Stir Vigorously

What probably should have remained someone's blog post about a visit to Western Kenya has been published in the Journal of Public Health. A young woman was taken to a 'disco funeral' in Western Kenya and was told about what happens during such events. The woman goes on to speculate about sexual behavior at funerals, HIV, and possible connections between the two.

However, the article reads like an uncritical and unreflective account of the experience of one white woman being invited to a funeral and attracting the interest of a drunken man while there, and does not seem to shed any light on the possible contribution of 'disco funerals' to HIV transmission, which is probably very small indeed.

The author appears to have believed everything she was told, and even found other published articles to support some of her claims. However, any kind of direct connection with HIV transmission seems tenuous for several reasons:

First, it is claimed that the Luhya of Western province and the Luo of Nyanza province engage in 'disco funerals'. Yet HIV prevalence is several times higher among the Luo than it is among the Luhya.

Second, these practices, as the author goes to some length to explain, take place in remote areas. Yet HIV prevalence is generally much lower in remote areas than it is in towns and cities.

Third, the entire account is anecdotal, it tells us nothing whatsoever about HIV.

Agreed, HIV is sometimes transmitted through unprotected sex, but not always. Evidence of 'unsafe' sexual behavior is not evidence of HIV transmission. Also, evidence of HIV transmission is not evidence of unsafe sexual behavior. The author of the article seems to have accepted both fallacies.

Clearly, there are social problems in these provinces, such as alcoholism, drug abuse, sexual abuse and the like, just as there are everywhere. But what is described in the articles and labelled as a 'cultural practice' sound very much like a funeral (albeit different from what the author may have experienced in Harvard, or anywhere else in the US).

The fact that some people drink too much and engage in various forms of behavior that can carry all kinds of risk, including sexual risk, does not make the events much different from parties, weddings and other get-togethers, that take place in many countries aside from Kenya, perhaps even in the US.

The term 'disco funeral' sounds very much like something made up by a journalist, perhaps similar to the one who wrote an article about this subject in IRIN, a publication that prefers a more sensationalist angle when addressing these 'issues'. But it seems unlikely that identifying social problems associated to a greater or lesser extent with funerals is the key to high HIV prevalence among some tribes in some places and low prevalence among other tribes in other places.

Various sources, apparently including academic journals, seem to publish just about anything about African countries, as long as it contains magic words like 'culture' and 'tradition', and florid descriptions of commonplace practices. But even identifying sexual practices that could be referred to as an aspect of 'culture' or 'tradition' does not necessarily tell us anything about how HIV is being transmitted.

Attacks on Albinos in Tanzania: Why is 'Investigation' Being Left to the Press?

I have spent many months over the last few years trying to understand what is really going on in Tanzania surrounding attacks on persons with albinism but I have run out of time and money to take it any further. However, I think that after more than seven years of these attacks it is imperative that we go beyond journalistic speculation and carry out proper investigations into the persecution, attacks, murders, and even the media coverage itself. It is disgraceful that these attacks continue, with little more than a bit of press frenzy every time another attack occurs. Many media articles are effectively putting a price on the head of every person with albinism, with their speculation and half baked 'research'. Below is an abstract of some preliminary research, up to 2013, that I would be happy to share with anyone interested in taking this further.

BACKGROUND

Before April 2006, superstitions about persons with albinism (PWA) were widely reported and many were subjected to prejudice and persecution, in Tanzania and elsewhere. But following an attack on a man with albinism in 2006 whose body was dismembered, a spate of attacks began in 2007 and continued until 2013, involving more than one hundred victims, about 35 of whom were murdered (although the media claim the number was over 70). The media covered these attacks assiduously in 2008 and 2009 but coverage plummeted in the following three years. Secondary literature includes reports by UN bodies and international NGOs, and these are found to depend to a large extent on earlier media reports, or on the same sources of information as those media reports.

METHODS

Using Google.com, a series of searches for the terms 'albino' and 'Tanzania' were carried out on a limited set of domain names, one by one, and a date search was used to ensure that articles from earlier years were also identified, resulting in a corpus of over 90 articles.

FINDINGS

Data was tabulated from the articles and described in narrative, including mentions of PWAs that predate attacks. Appendix I lists the full data: mentions of 'witchcraft' (or similar), a 'trade' in body parts, possible reasons for using body parts and potions made from them (such as wealth), and suggestions about who the perpetrators may have been. Very early on, the media identifies a pattern whereby 'witchdoctors' (or similar) engage paid middlemen to attack PWAs for their body parts; these would be used for 'spells' and 'potions' that would bestow some benefit, almost always wealth. The witchdoctors were said to be responding to a demand for these services from wealthy and powerful people, and that there was a 'lucrative trade' in body parts. Although numerous articles exhibit some or all aspects of this pattern it is unclear to what extent media accounts resemble what was happening on the ground, or to what extent what was happening on the ground was being influenced by the media.

DISCUSSION

It is concluded that the corpus of media coverage of attacks on PWAs from this period consists of sets of ‘received views’, exaggerated or purely imagined phenomena on which each story depends, to a greater or lesser extent; received views relate to witchcraft, the ‘trade in body parts’ and a whole array of perpetrators, while most incidents involving attacks on PWAs have never been adequately documented, and only a small number of people have been convicted of any offences.

RECOMMENDATIONS

The media needs to make it quite clear that there is, in fact, no evidence for the existence of a 'lucrative trade' in body parts, that if people try to make money this way they will fail because there are not enough ‘clients’ to buy body parts or 'potions' made from body parts in order to gain wealth or power, if there are any at all, and that the role played by witchcraft and other related phenomena is not at all clear, certainly not clear enough to attribute to it the kind of causality that the media claims; in addition to the failure to identify perpetrators, media coverage may have increased the risks that persons with albinism face, and attacks continue; even those suspected of being involved may have been subjected to persecution as a result of poorly researched media coverage.

UNAIDS Warns its Employees About Unsafe Healthcare in Africa, but not Africans

A senior epidemiologist at UNAIDS once argued that if unsafe healthcare was common in some African countries, hepatitis C prevalence in South Africa would also be high; the largest HIV positive population in the world is found there, but hepatitis C is not common. She insisted that HIV was mainly spread by heterosexual sex in Africa.

However, the simple answer is that hepatitis C was not around in South Africa to a great enough extent. If it had been around to any great extent it would have been transmitted sexually among the people who were said to engage in high levels of unsafe sex, as well as being spread by unsafe healthcare.

To the question of why HIV prevalence is not high in Egypt and other countries where hepatitis C was spread by unsafe healthcare, the answer is the same; HIV was not around to any great extent in Egypt when hepatitis was being spread. HIV arrived some time in the 1980s, after the injected treatment for mass schistosomiasis had been replaced by an oral dose. Otherwise HIV prevalence would be high in Egypt.

Recently I came across estimates of the 'sex worker' population in three countries with very different histories, Morocco, Kenya and South Africa.

Country	SW population	Population	HIV prevalence	People living with HIV	Urban population	Epidemic established
Morocco	70,000	33,000,000	0.1%	30,000	60%	Early 80s
Kenya	138,000*	42,000,000	6.1%	1,600,000	24%	50s
South Africa	138,000	54,000,000	17.9%	6,100,000	62%	70s

*This is an urban estimate, covering all towns of 5,000 or more people

The explanation that UNAIDS and others in the HIV industry give for differences in HIV epidemics always relates to sex. The typical argument about why prevalence is so low in Morocco and other northern African countries is that the populations are almost 100% Muslim, with some even claiming that male circumcision also protects men from HIV.

The sex worker population in Morocco is smaller than those in Kenya and South Africa (although the numbers for Kenya do seem pretty high, considering the urban population only includes about one quarter of people). But it is the figures for HIV prevalence and people living with HIV that are completely out of proportion.

Prevalence in Kenya is 61 times higher than prevalence in Morocco and prevalence in South Africa is 179 times higher. Are we expected to believe that the very different environments and histories found in these three countries, emerging over many decades and centuries, all result in an impact on sexual behavior alone, and that is as staggering as these figures suggest?

Surely there are some other important differences? For example, infrastructure is much better developed in South Africa than in Kenya. But much of Morocco is desert. More importantly, the Sahara may have protected countries around it from HIV. Health services are also better developed in South Africa.

HIV established itself in East Africa in the 1950s and had infected hundreds of thousands of people by the 1970s. The virus was not established in South Africa until the 1970s and by 1990 prevalence was still very low. So the majority of the six million infections occurred after 1990. But HIV only arrived in Morocco in the 1980s, from Europe, and it never really spread that widely.

Perhaps sexual behavior in Muslim countries is different from sexual behavior in non-Muslim countries. But numbers of sex workers, men who have sex with men and others suggest that it could not be differences in sexual behavior alone that accounts for huge differences in HIV prevalence and numbers of people infected.

The histories of countries where HIV failed to spread can be as enlightening as those of countries where the virus spread widely when it comes to understanding why a few countries have appalling epidemics, whereas others have relatively small ones. HIV spread most successfully in southern Africa, less successfully in eastern Africa and not very successfully in northern Africa.

Some have suggested that HIV was spread by unsafe healthcare several decades ago, but that sexual transmission took over in the 1970s or 1980s and that it now accounts for 80% or more of all transmission. But there is no evidence for this anomalous transition, with healthcare suddenly becoming safe and heterosexual sex becoming rampant, but only in some countries.

Even UNAIDS themselves don't believe that healthcare is safe in African countries. They warn their own employees to avoid 'non-UN approved' health facilities and people are advised to carry their own syringes and needles. Tourists from wealthy countries are similarly warned when they are travelling in African countries. So why are African people not warned about the risks and how to avoid them?