It seems that UNAIDS and the Vatican are sort of agreeing about condoms. UNAIDS haven't managed to persuade very many people to use them frequently and consistently enough to reduce sexually transmitted infection rates (STI) or unplanned pregnancies.
And the Vatican doesn't care whether STI rates or unplanned pregnancy rates are reduced as long as no 'sins' are seen to be committed in the process. But in most Catholic countries, especially rich ones, people take little enough notice of the preachings of the church.
The two institutions have a lot in common. They are both massively wealthy, unelected and virtually unaccountable, packed with some of the most educated people in their field, slow to change and often utterly oblivious to what goes on in the outside world.
The invitation of Dr Michel Sidibe, executive director of UNAIDS, to speak at a conference at the Vatican is seen as significant because the Vatican "usually only invites like-minded outsiders to its conferences and UNAIDS has not been like-minded on this issue at all".
I think that's an exaggeration. Sidibe may have come down on the side of condoms and stressed abstinence and marital fidelity a little less, while the Vatican has stressed abstinence and marital infidelity more and appeared to rail against condoms.
But both parties wish to influence the sexual behavior of poor people and seem hell bent on doing so. Both Sidibe and the pope know that talk about abstinence and marital fidelity are just talk. So far, UNAIDS have made do with putting a brave face on the results of their 'prevention' programs and the Catholic church has long had to put up with keeping the lid on reality.
Let's face it, neither institution has really aimed to reduce HIV transmission very convincingly. Both have done everything in their power to protect their own interests, although those interests are not always completely clear.
In truth, condoms are about all we have to reduce sexually transmitted HIV. There is a lot of talk about other measures, microbicides, pre-exposure prophylaxis, treatment as prevention, circumcision and probably a few others. But all of these are recommended in conjunction with the consistent and correct use of condoms.
Catholics have long ignored the pope's pronouncements about certain things, including contraception, abortion, homosexuality, pre-marital sex and much else. Even many of the popes own leaders have been shown to enjoy a varied sex life, even if their ways of expressing their sexuality might not be so popular among their followers.
If the technocrats and multinationals are even close to being right in claiming that one or several of their offerings will one day significantly reduce HIV transmission, at least in certain contexts, the two mammoths may even be able to publicly agree on things, about condoms, health, even sex.
That would be interesting because neither party would end up being able to control people's sexual behavior in the ways they might wish. If any of these technological solutions can reduce HIV transmission, any incentive to use condoms or adopt any of the other strictures of 'safe sex', imagined or otherwise, will disappear.
I don't think anyone seriously believes HIV will just be wiped out in the forseeable future. Sadly, HIV transmission is going to continue to be high enough to infect huge numbers of people, but mainly in developing countries.
There is a lot of enthusiasm for something that looks like a solution, preferably just one single measure, rather than a combination of measures. Sidibe calls 'treatment as prevention' a game-changer, but it might also result in the almost total irrelevance of these two vast institutions.
Now is not the time to start backtracking on condoms. HIV is a matter of health, something neither of these institutions know anything about. We badly need an institution that can represent the health related interests of people, especially poor people living in developing countries. We don't need any more vested interests stealing the health agenda. So let's kiss the Vatican and UNAIDS goodbye and start working on HIV.
Tuesday, May 31, 2011
Sunday, May 29, 2011
Killing Kenyans, Saving UN Employees: it's a matter of priorities
I'm still trying to reconcile two claims from UNAIDS: the first is that 80% of HIV transmission is a result of heterosexual sex in African countries (in most non-African countries it's mainly a result of male to male anal sex and intravenous drug use). An estimated 18% of transmission in African countries is from mother to child. And only the remaining 2% is a result of unsafe health care.
The second claim is that "We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere."
Evidently, non-UN approved hospitals do not take all the necessary precautions to prevent accidental exposure to contaminated blood, nor can they be guaranteed to use new or sterilized equipment. The 2% figure estimated (and it is an estimate, no empirical data has ever been made available to support it) is so low, it can be assumed that only the kind of small clinics found in outlying areas would be responsible for much of it.
So why the need to warn UN employees? There is certainly no danger to them. Or, turning things around, why is there no need to warn Kenyans and other Africans? Most poor Kenyans will rarely see a doctor and much of the treatment they receive will be rushed, performed by badly trained, badly supervised, underequipped personnel, perhaps even people who know nothing about infection control.
Because many people working in health know little about infection control. Many health facilities have few infection control supplies, people who know how to use them or studies to find out if the little available is ever utilized. UN employees are probably in little danger when it comes to health care. But Kenyans face many dangers.
The latest Service Provision Assessment for Kenya (2010) is now available from the MeasureDHS website. This assesses the availability and quality of services from a representative sample of over 700 health facilities, ranging from regional hospitals to voluntary counselling and testing (VCT)acentres to dispensaries and small, rural clinics.
When it comes to infection control, the survey makes especially sorry reading. Only 80% of standalone VCT clinics have both soap and water. The figures for all other types of health facility are even lower, with only 30% or fewer hospitals, health centres and maternity facilities having such basic items.
While 93% of VCT clinics manage to have clean latex or sterile gloves, only two thirds of hospitals and health centres do, and less than 80% of materity facilities do. In fact, only 12% of hospitals have all the basic items needed for infection control. Again, the highest figure is from VCT clinics, where 66% 'make the grade'.
When it comes to supplies of items needed, fewer than 30% of facilities in all categories have all the items and none of the VCT clinics have all of them. It may not be so bad for only 14% of VCT clinics to have supplies of needles and syringes. But only 89% of hospitals, 86% of health centres and 93% of maternity facilities have them.
As for the disposal of contaminated waste, especially sharps, such as needles and scalpels, the majority of facilities don't even have the basics. Sterilization equipment is lacking in many and, even where it exists, there are often no people or equipment to ensure its use. Written guidelines or procedures are also missing in the majority of facilities.
As the Service Provision Assessment itself makes clear, the presence of trained personnel, equipment, guidelines or anything else gives no indication of whether infection control actually takes place, how often and to what extent. If there are any serious breeches, they are unlikely even to be logged, let alone investigated or addressed.
So it seems that UN employees probably do need to be warned. But if so, ordinary Kenyans and other Africans are in far greater danger than pampered foreigners who travel in air conditioned vehicles and have access to some of the best facilities and expertise in the world, and that's not just in health care, either.
Kenyans and other Africans need to be aware that the state of their health facilities is such that their safety from blood borne and other infections is most definitely not assured. Kenyan hospitals are shabby, understaffed and underequipped. It is not clear how much HIV (or other diseases) have been spread by health care procedures because the matter has never been investigated. But it is time to investigate now.
The second claim is that "We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere."
Evidently, non-UN approved hospitals do not take all the necessary precautions to prevent accidental exposure to contaminated blood, nor can they be guaranteed to use new or sterilized equipment. The 2% figure estimated (and it is an estimate, no empirical data has ever been made available to support it) is so low, it can be assumed that only the kind of small clinics found in outlying areas would be responsible for much of it.
So why the need to warn UN employees? There is certainly no danger to them. Or, turning things around, why is there no need to warn Kenyans and other Africans? Most poor Kenyans will rarely see a doctor and much of the treatment they receive will be rushed, performed by badly trained, badly supervised, underequipped personnel, perhaps even people who know nothing about infection control.
Because many people working in health know little about infection control. Many health facilities have few infection control supplies, people who know how to use them or studies to find out if the little available is ever utilized. UN employees are probably in little danger when it comes to health care. But Kenyans face many dangers.
The latest Service Provision Assessment for Kenya (2010) is now available from the MeasureDHS website. This assesses the availability and quality of services from a representative sample of over 700 health facilities, ranging from regional hospitals to voluntary counselling and testing (VCT)acentres to dispensaries and small, rural clinics.
When it comes to infection control, the survey makes especially sorry reading. Only 80% of standalone VCT clinics have both soap and water. The figures for all other types of health facility are even lower, with only 30% or fewer hospitals, health centres and maternity facilities having such basic items.
While 93% of VCT clinics manage to have clean latex or sterile gloves, only two thirds of hospitals and health centres do, and less than 80% of materity facilities do. In fact, only 12% of hospitals have all the basic items needed for infection control. Again, the highest figure is from VCT clinics, where 66% 'make the grade'.
When it comes to supplies of items needed, fewer than 30% of facilities in all categories have all the items and none of the VCT clinics have all of them. It may not be so bad for only 14% of VCT clinics to have supplies of needles and syringes. But only 89% of hospitals, 86% of health centres and 93% of maternity facilities have them.
As for the disposal of contaminated waste, especially sharps, such as needles and scalpels, the majority of facilities don't even have the basics. Sterilization equipment is lacking in many and, even where it exists, there are often no people or equipment to ensure its use. Written guidelines or procedures are also missing in the majority of facilities.
As the Service Provision Assessment itself makes clear, the presence of trained personnel, equipment, guidelines or anything else gives no indication of whether infection control actually takes place, how often and to what extent. If there are any serious breeches, they are unlikely even to be logged, let alone investigated or addressed.
So it seems that UN employees probably do need to be warned. But if so, ordinary Kenyans and other Africans are in far greater danger than pampered foreigners who travel in air conditioned vehicles and have access to some of the best facilities and expertise in the world, and that's not just in health care, either.
Kenyans and other Africans need to be aware that the state of their health facilities is such that their safety from blood borne and other infections is most definitely not assured. Kenyan hospitals are shabby, understaffed and underequipped. It is not clear how much HIV (or other diseases) have been spread by health care procedures because the matter has never been investigated. But it is time to investigate now.
Wednesday, May 25, 2011
Gates 'New' Model of Development is the Old One, But With Higher Returns
The biggest producer of genetically modified organisms (GMO) in the world is the US, by a very long shot. The EU doesn't produce them comercially at all. So why is the number of tons of cereal per acre the same for both geographic regions? If GM is the answer, yield per acre should surely be a lot higher in the US. Of course, the figures could be rubbish, I got them from the Gates Foundation site.
The figure comes from one of Gates' sick-making speeches about Nora's goat, Tommy's piles or some happy, healthy (but African) toddler's ambitions to be prime minister. But behind the sugar coating there is, apparently, a pill; a pill to cure all of Africa's problems.
You might think that pill is GMO, but that's just one of a range of pills that have something in common: intellectual property rights have that not expired.
The strategy starts with "Innovation in seeds [which] brings small farmers new high-yield crops that can grow in a drought, survive in a flood, and resist pests and disease".
Some comments are in order. The majority of crops that have all, or even any of these advantages, are not genetically modified. So, no sugar for them. And these crops, whether GM or otherwise, are not developed, despite Gates' constant reference to them, for small farmers.
The few GM crops that have any of these advantages, none of them have all the advantages, also have some serious disadvantages, what Gates might call 'challenges'. For example, the seeds cost a lot more than conventionally bred seeds, resistance to pests gives rise to resistant pests, giving rise to further costs, etc. I say 'etc' because no commercially available GM crop has been developed with resistance to flooding or drought.
"Innovation in markets offers small farmers access to reliable customers." Now, what markets would he be talking about? The World Food Program and it's 'Purchase for Progress initiative, supported by Gates, which purchases a proportion of food aid from developing countries, or aims to. Apparently one of the Noras or Tommys quadrupled their income in one year as a result of this program.
Or perhaps Gates is talking about the US and EU markets, which subsidise some of their farmers so heavily that cotton and sugar, for example, can be grown more cheaply in the richest countries in the world than they can be in the poorest? Could the US and EU become 'reliable customers'? As things stand, the EU will cease to be customers as they don't accept any GMO contaminated foods for human consumption. So they say, anyhow.
"Innovation in agricultural techniques helps farmers increase productivity while preserving the environment – with approaches like no-till farming, rainwater harvesting, and drip irrigation." No-till farming may or may not require the use of GMOs. But rainwater harvesting and drip irrigation neither requires nor excludes them. The question is, will the Foundation require GMOs or, at least, crops that involve rich country protectionism, in the form of intellectual property rights? I'm guessing that not a lot of money will be spent on these 'challenges'.
"Innovation in foreign assistance assistance means that donors now support national plans that provide farming families with new seeds, tools, techniques and markets." So the rich countries that are making so much money screwing poor countries are going to suddenly concentrate their efforts on alleviating poverty that they have gone to so much effort to create? Keep dreaming Bill.
Following 'Purchase for Progress', there is now 'Feed the Future', of which Gates is also a keen supporter. And why wouldn't he be, with some of the top names in agriculture and food multinationals behind it?
Bill says his strategy has nothing to do with the "old aid model of donors and recipients". Actually, it has everything to do with the old aid model: it guarantees that the model of giving to people from whom you know you can extort a hell of a lot more will work far better if you also take control of the recipients' means of production. That's what's wrong with GMOs and with Gates.
The figure comes from one of Gates' sick-making speeches about Nora's goat, Tommy's piles or some happy, healthy (but African) toddler's ambitions to be prime minister. But behind the sugar coating there is, apparently, a pill; a pill to cure all of Africa's problems.
You might think that pill is GMO, but that's just one of a range of pills that have something in common: intellectual property rights have that not expired.
The strategy starts with "Innovation in seeds [which] brings small farmers new high-yield crops that can grow in a drought, survive in a flood, and resist pests and disease".
Some comments are in order. The majority of crops that have all, or even any of these advantages, are not genetically modified. So, no sugar for them. And these crops, whether GM or otherwise, are not developed, despite Gates' constant reference to them, for small farmers.
The few GM crops that have any of these advantages, none of them have all the advantages, also have some serious disadvantages, what Gates might call 'challenges'. For example, the seeds cost a lot more than conventionally bred seeds, resistance to pests gives rise to resistant pests, giving rise to further costs, etc. I say 'etc' because no commercially available GM crop has been developed with resistance to flooding or drought.
"Innovation in markets offers small farmers access to reliable customers." Now, what markets would he be talking about? The World Food Program and it's 'Purchase for Progress initiative, supported by Gates, which purchases a proportion of food aid from developing countries, or aims to. Apparently one of the Noras or Tommys quadrupled their income in one year as a result of this program.
Or perhaps Gates is talking about the US and EU markets, which subsidise some of their farmers so heavily that cotton and sugar, for example, can be grown more cheaply in the richest countries in the world than they can be in the poorest? Could the US and EU become 'reliable customers'? As things stand, the EU will cease to be customers as they don't accept any GMO contaminated foods for human consumption. So they say, anyhow.
"Innovation in agricultural techniques helps farmers increase productivity while preserving the environment – with approaches like no-till farming, rainwater harvesting, and drip irrigation." No-till farming may or may not require the use of GMOs. But rainwater harvesting and drip irrigation neither requires nor excludes them. The question is, will the Foundation require GMOs or, at least, crops that involve rich country protectionism, in the form of intellectual property rights? I'm guessing that not a lot of money will be spent on these 'challenges'.
"Innovation in foreign assistance assistance means that donors now support national plans that provide farming families with new seeds, tools, techniques and markets." So the rich countries that are making so much money screwing poor countries are going to suddenly concentrate their efforts on alleviating poverty that they have gone to so much effort to create? Keep dreaming Bill.
Following 'Purchase for Progress', there is now 'Feed the Future', of which Gates is also a keen supporter. And why wouldn't he be, with some of the top names in agriculture and food multinationals behind it?
Bill says his strategy has nothing to do with the "old aid model of donors and recipients". Actually, it has everything to do with the old aid model: it guarantees that the model of giving to people from whom you know you can extort a hell of a lot more will work far better if you also take control of the recipients' means of production. That's what's wrong with GMOs and with Gates.
Monday, May 23, 2011
Mix Vaccine With Contaminated Water and Swallow
I've ceased to expect much from the English Guardian on the subject of development now that their development section is "in partnership with the Bill and Melinda Gates Foundation". But a recent blog post from the section takes pretty much the opposite stance to that of the Gates Politbureau when it comes to the question of basic water, sanitation and hygiene over vaccination.
The Gates publicity machine tends to gush about vaccines, about how they are the future of health and development, about how they are investing $10 billion in them, advocating for a 'decade of vaccines', etc. This flies in the face of public health experience over many decades. For Gates, public health means giving people some drugs and letting them swallow them with contaminated water.
But according to the Guardian article, the World Health Organization estimates that 10% of global disease could be prevented through the provision of safe water, sanitation and hygiene facilities. That estimate sounds rather low, especially for infant and childhood diseases. But at least it is recongized that conditions such as cholera and guinea worm can not be eradicated without providing people with the basics.
Gates, on the other hand, wishes to sink much of his Foundation's money into a vaccine for cholera and polio, with only dribs and drabs going to WASH. And it's not just the Foundation's money that is involved here. It seems that when the Foundation makes a pronouncement about anything, regardless of its serious lack of understanding of the issues, global policy does likewise.
The massive cholera epidemic currently raging in Haiti is a result of a lack of water, sanitation and hygiene services in the country. This lack is not purely a result of some recent disasters, either. The country has been left dangerously underdeveloped as a result of numerous factors, many of them political. Even if a vaccine was available, people would be unlikely to have received it in Haiti and they would likely have been infected with many of the other water borne diseases that are as debilitating and deadly as cholera.
The author of the Guardian article, Yael Velleman, is a policy analyst at WaterAid. The article also calls for closer cooperation between government departments responsible for health, on the one hand, and water, sanitation and hygiene, on the other. This means that donors and those working in development need to connect these two development themes and recognize that they are interdependent.
So, yes to vaccines and other medical technologies. But without better living conditions, they will make little or no difference to people's lives. WASH must come first because without it vaccines will be useless. If you don't believe me, carry out this quick thought experiment: mix vaccine with water drawn from the nearest source of contaminated water and swallow.
These are excellent and sobering insights from WaterAid and Yael Velleman, in particular. There is more on the above issues on their website, including some clarification of the Gates Foundation's stance on immunization and how inimical it is to development (my words, not hers!). The issue is covered in pictures in another Guardian article.
The Gates publicity machine tends to gush about vaccines, about how they are the future of health and development, about how they are investing $10 billion in them, advocating for a 'decade of vaccines', etc. This flies in the face of public health experience over many decades. For Gates, public health means giving people some drugs and letting them swallow them with contaminated water.
But according to the Guardian article, the World Health Organization estimates that 10% of global disease could be prevented through the provision of safe water, sanitation and hygiene facilities. That estimate sounds rather low, especially for infant and childhood diseases. But at least it is recongized that conditions such as cholera and guinea worm can not be eradicated without providing people with the basics.
Gates, on the other hand, wishes to sink much of his Foundation's money into a vaccine for cholera and polio, with only dribs and drabs going to WASH. And it's not just the Foundation's money that is involved here. It seems that when the Foundation makes a pronouncement about anything, regardless of its serious lack of understanding of the issues, global policy does likewise.
The massive cholera epidemic currently raging in Haiti is a result of a lack of water, sanitation and hygiene services in the country. This lack is not purely a result of some recent disasters, either. The country has been left dangerously underdeveloped as a result of numerous factors, many of them political. Even if a vaccine was available, people would be unlikely to have received it in Haiti and they would likely have been infected with many of the other water borne diseases that are as debilitating and deadly as cholera.
The author of the Guardian article, Yael Velleman, is a policy analyst at WaterAid. The article also calls for closer cooperation between government departments responsible for health, on the one hand, and water, sanitation and hygiene, on the other. This means that donors and those working in development need to connect these two development themes and recognize that they are interdependent.
So, yes to vaccines and other medical technologies. But without better living conditions, they will make little or no difference to people's lives. WASH must come first because without it vaccines will be useless. If you don't believe me, carry out this quick thought experiment: mix vaccine with water drawn from the nearest source of contaminated water and swallow.
These are excellent and sobering insights from WaterAid and Yael Velleman, in particular. There is more on the above issues on their website, including some clarification of the Gates Foundation's stance on immunization and how inimical it is to development (my words, not hers!). The issue is covered in pictures in another Guardian article.
Wednesday, May 18, 2011
Low Figures for Hospital Acquired Infections Due to Lack of Research
The UN development news agency IRIN has an article entitled 'For want of a mask', about TB in health workers. Masks are cheap, but vital, to comply with all sorts of procedures. So why would health workers lack something so basic, something that can protect both health workers and patients?
The Service Provision Assessment for Kenya, produced by Demographic and Health Surveys, shows that masks are not all Kenyan health facilities lack. Running water is available in about half of all facilities, soap in 70%, latex gloves in 87%, sharps disposal box in 73% and chlorine solution in only 28% of facilities.
That's 15% who have all items for relevant service areas. When it comes to stocks of infection control items,things little better. While 89% have high level sterilization equipment, bleach and injecting equipment, only half have latex gloves and only 40% have all items in stock. So only 3% of Kenyan facilities have everything they need.
So it's not just TB infection that people need worry about, there are also blood borne infections, such as HIV, hepatitis and bacterial infections, amongst others. But TB is exceptionally high in Kenya considering it is so commonly associated with HIV. Because, while Kenya is fifth highest in Africa for TB burden, HIV prevalence there is a lot lower than in the five highest HIV prevalence countries.
The article on TB makes it clear that even where safety supplies are lacking, health services still have to be supplied. Health personnel and patients face considerable risks of being infected through the health facility and health related procedures, testing, treatment or preventative, rather than through normal person to person contact.
Apparently supply chains, funding, management, theft and corruption have all been blamed for shortages. Drugs also, are said to be in short supply, for similar reasons. Equipment, drugs and other items can even be sold off to private pharmacies.
In addition to shortages of supplies, there is also the problem of use. Even when masks are available they are not always used. Some supplies may be misused, with gloves and perhaps other items being reused. That certainly happens in wealthy countries, where such matters are routinely investigated, so it would be unsurprising if it didn't happen in destitute countries.
An article on safe injection practices finds that there have been 30 infectious disease outbreaks in the last ten years in the US and they call for education, research and better products to ensure safe injection. More than 125,000 patients have been notified about potential exposure due to reuse of syringes.
Even if injection equipment reuse in Africa was only as high as that in the US, that would mean about 400,000 people could have been exposed. But the number notified, apparently, is zero. Not only do Africans not get recalled under such circumstances, but injection reuse hardly ever occurs in African countries, according to UNAIDS and others. And that is despite the figures from the Kenyan Service Provision Assessment, cited above.
Given conditions in Kenyan health facilities, I think it is fair to say that there is far more scope for hospital transmitted infection there than in the worst US hospital. I can't cite any research to back up that claim because virtually no research has been done on infection control in African countries. And that's what makes me question the figure UNAIDS gives for the contribution of unsafe health care to Kenya's HIV epidemic, 2%. Where is their research?
The Service Provision Assessment for Kenya, produced by Demographic and Health Surveys, shows that masks are not all Kenyan health facilities lack. Running water is available in about half of all facilities, soap in 70%, latex gloves in 87%, sharps disposal box in 73% and chlorine solution in only 28% of facilities.
That's 15% who have all items for relevant service areas. When it comes to stocks of infection control items,things little better. While 89% have high level sterilization equipment, bleach and injecting equipment, only half have latex gloves and only 40% have all items in stock. So only 3% of Kenyan facilities have everything they need.
So it's not just TB infection that people need worry about, there are also blood borne infections, such as HIV, hepatitis and bacterial infections, amongst others. But TB is exceptionally high in Kenya considering it is so commonly associated with HIV. Because, while Kenya is fifth highest in Africa for TB burden, HIV prevalence there is a lot lower than in the five highest HIV prevalence countries.
The article on TB makes it clear that even where safety supplies are lacking, health services still have to be supplied. Health personnel and patients face considerable risks of being infected through the health facility and health related procedures, testing, treatment or preventative, rather than through normal person to person contact.
Apparently supply chains, funding, management, theft and corruption have all been blamed for shortages. Drugs also, are said to be in short supply, for similar reasons. Equipment, drugs and other items can even be sold off to private pharmacies.
In addition to shortages of supplies, there is also the problem of use. Even when masks are available they are not always used. Some supplies may be misused, with gloves and perhaps other items being reused. That certainly happens in wealthy countries, where such matters are routinely investigated, so it would be unsurprising if it didn't happen in destitute countries.
An article on safe injection practices finds that there have been 30 infectious disease outbreaks in the last ten years in the US and they call for education, research and better products to ensure safe injection. More than 125,000 patients have been notified about potential exposure due to reuse of syringes.
Even if injection equipment reuse in Africa was only as high as that in the US, that would mean about 400,000 people could have been exposed. But the number notified, apparently, is zero. Not only do Africans not get recalled under such circumstances, but injection reuse hardly ever occurs in African countries, according to UNAIDS and others. And that is despite the figures from the Kenyan Service Provision Assessment, cited above.
Given conditions in Kenyan health facilities, I think it is fair to say that there is far more scope for hospital transmitted infection there than in the worst US hospital. I can't cite any research to back up that claim because virtually no research has been done on infection control in African countries. And that's what makes me question the figure UNAIDS gives for the contribution of unsafe health care to Kenya's HIV epidemic, 2%. Where is their research?
Monday, May 16, 2011
Biological Factors that May Contribute to Huge Disparities in HIV Prevalence
The brief summary at the end of an excellent article on 'Biological Factors that May Contribute to Regional and Racial Disparities in HIV Prevalence' really gets to the point about how HIV prevention should be approached, but generally isn't:
"To develop better prevention tools, it is critical that communities, researchers and policy makers come together to discuss and investigate these tremendous [racial disparities in HIV prevalence, both between regions and within regions] in an open and non-judgmental fashion."
Instead, it is generally assumed that HIV transmission is driven by "stigmatizing socio-behavioural factors such as sexual concurrency or promiscuity, partner violence and so on." This article emphasizes that "biological factors such as endemic co-infections and immunology also play a key role."
The authors warn against blaming affected communities and individuals, something the HIV mainstream have been guilty of while at the same time, rather perversely, warning those in high prevalence communities that they should avoid stigmatizing attitudes. The highest prevalence figures are found in a handful of African countries and in specific regions in some countries.
Occasional mention is made about how inefficient heterosexual sex is when it comes to transmitting HIV, but without any logical conclusions being drwan from that fact. While the probability of transmission resulting from penile-vaginal sex appears to be higher in African countries, such transmission is still "the rare exception rather than the rule."
Co-infections with diseases common in African countries, such as TB, malaria (see also this abstract on malaria as a co-factor in HIV transmission) and various kinds of parasitic conditions may increase transmission by those infected with HIV and increase susceptibility in those uninfected. While it has been recognised that could treating these conditions would reduce transmission, no clinical trials have assessed the impact this might have.
Similar remarks apply to various sexually transmitted infections (STI). But while some trials have looked at reducing STIs as a means of reducing HIV transmission, factors such as non-sexual HIV transmission, perhaps through the STI treatment itself, may not have been taken into account. So not enough is yet known about this kind of intervention.
Male circumcision is discussed and the authors mention that HIV prevalence is higher in a non-circumcising population in Kenya's Nyanza's province. However, they don't mention that there are non-circumcising populations in other countries where HIV prevalence is lower than in circumcising populations.
Also, low HIV prevalence is often correlated with female genital mutilation (FGM), even in Nyanza province itself. The Luo tribe may not circumcise their men, but they don't circumcise their women either. Whereas in tribes that circumcise men and women, such as the Kisii, HIV prevalence is lower than national prevalence. Other tribes that practice FGM, such as the Somali, have even lower HIV prevalence than the Kisii.
Personally, I am opposed to FGM, but the arguments for male circumcision seem equally unconvincing. Some even claim that male circumcision reduces the number of Langerhans cells, which HIV targets. But there are Langerhans cells in the vagina as well and no one would argue that parts of it should be surgically removed to reduce susceptibility to HIV infection.
But if you are opposed to the view that Africans have extraordinary and probably animalistic sex lives, that they care little for their own health and welfare, or for that of their partners and their children, you need to read the above article.
"To develop better prevention tools, it is critical that communities, researchers and policy makers come together to discuss and investigate these tremendous [racial disparities in HIV prevalence, both between regions and within regions] in an open and non-judgmental fashion."
Instead, it is generally assumed that HIV transmission is driven by "stigmatizing socio-behavioural factors such as sexual concurrency or promiscuity, partner violence and so on." This article emphasizes that "biological factors such as endemic co-infections and immunology also play a key role."
The authors warn against blaming affected communities and individuals, something the HIV mainstream have been guilty of while at the same time, rather perversely, warning those in high prevalence communities that they should avoid stigmatizing attitudes. The highest prevalence figures are found in a handful of African countries and in specific regions in some countries.
Occasional mention is made about how inefficient heterosexual sex is when it comes to transmitting HIV, but without any logical conclusions being drwan from that fact. While the probability of transmission resulting from penile-vaginal sex appears to be higher in African countries, such transmission is still "the rare exception rather than the rule."
Co-infections with diseases common in African countries, such as TB, malaria (see also this abstract on malaria as a co-factor in HIV transmission) and various kinds of parasitic conditions may increase transmission by those infected with HIV and increase susceptibility in those uninfected. While it has been recognised that could treating these conditions would reduce transmission, no clinical trials have assessed the impact this might have.
Similar remarks apply to various sexually transmitted infections (STI). But while some trials have looked at reducing STIs as a means of reducing HIV transmission, factors such as non-sexual HIV transmission, perhaps through the STI treatment itself, may not have been taken into account. So not enough is yet known about this kind of intervention.
Male circumcision is discussed and the authors mention that HIV prevalence is higher in a non-circumcising population in Kenya's Nyanza's province. However, they don't mention that there are non-circumcising populations in other countries where HIV prevalence is lower than in circumcising populations.
Also, low HIV prevalence is often correlated with female genital mutilation (FGM), even in Nyanza province itself. The Luo tribe may not circumcise their men, but they don't circumcise their women either. Whereas in tribes that circumcise men and women, such as the Kisii, HIV prevalence is lower than national prevalence. Other tribes that practice FGM, such as the Somali, have even lower HIV prevalence than the Kisii.
Personally, I am opposed to FGM, but the arguments for male circumcision seem equally unconvincing. Some even claim that male circumcision reduces the number of Langerhans cells, which HIV targets. But there are Langerhans cells in the vagina as well and no one would argue that parts of it should be surgically removed to reduce susceptibility to HIV infection.
But if you are opposed to the view that Africans have extraordinary and probably animalistic sex lives, that they care little for their own health and welfare, or for that of their partners and their children, you need to read the above article.
Saturday, May 14, 2011
Three Cheers For HIV Treatment, Only One For Prevention
The news that treating HIV early can significantly reduce transmission in discordant couples, where only one partner is positive, is very good indeed. It should provide some impetus for increasing considerably the number of people receiving treatment, and at an earlier stage of disease progression. This should give a high level of protection to people with HIV positive partners, if the 96% protection in the trial is anything to go by.
It remains to be seen whether funding for the number of people currently on treatment will be doubled, especially as the costs of treatment go way beyond the costs of antiretroviral drugs, which have attracted much of the funding so far. And many donors are reluctant to even keep funding at its current levels.
But the same research shows that treating HIV is not enough to prevent transmission to the extent that it can be completely eradicated in the forseeable future. Among the 39 new HIV infections in the study, only about 70% were clearly transmitted by the HIV positive partner. The others were either transmitted by a different partner, or perhaps were transmitted non-sexually.
In addition, in some countries, a very high percentage of new HIV infections occur in stable relationships. But many of these infections occur where neither partner was previously infected. This is what gives rise to concurrency in the first place. But it is not always clear how or why some people are infected when their partner is not.
Of course, some instances may be simply a matter of one partner either having a sexual relationship with someone who is not their partner or being infected in some other way. But other instances are not so easily explained away. In some countries, about half of these occurrences involve women being infected, but not by their partner, the other half men.
Anyone can speculate about the sexual behavior of people who become infected, but many years of studies in many countries involving tens of thousands of people show that HIV transmission is not very closely correlated with sexual behavior that is considered to carry a high risk of HIV infection.
Often, those who use condoms the most, have the fewest sexual partners (sometimes none at all), have the fewest 'risky' sexual experiences and know all they need to know about 'safe' sex appear to be the most likely to be HIV positive. While certain people are being infected sexually, it is by no means clear that this is the main route of infection in other groups.
So HIV treatment is vital for HIV positive people and it may also prevent infection in some scenarios. But it is by no means enough to ensure that HIV transmission levels are lowered to a position where HIV will become a thing of the past. The very fact that so many people are still being infected years after antiretrovirals have been available to millions of people shows that prevention needs to include more than just treating greater numbers of people and treating them earlier.
And not really knowing how most people became infected in the first place is a big gap in our understanding. There is quite an absurdity in thinking that we can make a serious dent in the worst HIV epidemics when we don't really know why so many people are becoming infected, apparently sexually, with a virus that is relatively difficult to transmit sexually.
The news is good for HIV negative people in discordant relationships, but not for HIV negative people who are not in discordant relationships. And while HIV positive people need treatment, many might still question how they became infected in the first place when their partner is not infected. Prevention has received very little attention so far, so let's not allow the scaling up of treatment to deflect attention even further.
It remains to be seen whether funding for the number of people currently on treatment will be doubled, especially as the costs of treatment go way beyond the costs of antiretroviral drugs, which have attracted much of the funding so far. And many donors are reluctant to even keep funding at its current levels.
But the same research shows that treating HIV is not enough to prevent transmission to the extent that it can be completely eradicated in the forseeable future. Among the 39 new HIV infections in the study, only about 70% were clearly transmitted by the HIV positive partner. The others were either transmitted by a different partner, or perhaps were transmitted non-sexually.
In addition, in some countries, a very high percentage of new HIV infections occur in stable relationships. But many of these infections occur where neither partner was previously infected. This is what gives rise to concurrency in the first place. But it is not always clear how or why some people are infected when their partner is not.
Of course, some instances may be simply a matter of one partner either having a sexual relationship with someone who is not their partner or being infected in some other way. But other instances are not so easily explained away. In some countries, about half of these occurrences involve women being infected, but not by their partner, the other half men.
Anyone can speculate about the sexual behavior of people who become infected, but many years of studies in many countries involving tens of thousands of people show that HIV transmission is not very closely correlated with sexual behavior that is considered to carry a high risk of HIV infection.
Often, those who use condoms the most, have the fewest sexual partners (sometimes none at all), have the fewest 'risky' sexual experiences and know all they need to know about 'safe' sex appear to be the most likely to be HIV positive. While certain people are being infected sexually, it is by no means clear that this is the main route of infection in other groups.
So HIV treatment is vital for HIV positive people and it may also prevent infection in some scenarios. But it is by no means enough to ensure that HIV transmission levels are lowered to a position where HIV will become a thing of the past. The very fact that so many people are still being infected years after antiretrovirals have been available to millions of people shows that prevention needs to include more than just treating greater numbers of people and treating them earlier.
And not really knowing how most people became infected in the first place is a big gap in our understanding. There is quite an absurdity in thinking that we can make a serious dent in the worst HIV epidemics when we don't really know why so many people are becoming infected, apparently sexually, with a virus that is relatively difficult to transmit sexually.
The news is good for HIV negative people in discordant relationships, but not for HIV negative people who are not in discordant relationships. And while HIV positive people need treatment, many might still question how they became infected in the first place when their partner is not infected. Prevention has received very little attention so far, so let's not allow the scaling up of treatment to deflect attention even further.
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