Hospitals Are Spreading HIV, Say WHO, UNAIDS and World Bank, But Only a Little

The open letter sent to Michel Sidibé, Executive Director of UNAIDS, Margaret Chan, Director General of WHO and Jim Kim, President of the World Bank received a response that is the equivalent of answering a question by referring back to the very data that prompted the question in the first place. Between one sixth and one third of HIV positive children under 5 years old have HIV negative mothers in the four countries where it was deemed important enough to test for this phenomenon.

Clearly, three of the top institutions involved in health and HIV in developing countries demand a better reason to investigate safety in health and cosmetic facilities, where skin-piercing procedures may be transmitting HIV and other blood-borne diseases. The reuse of unsterile injecting and other equipment has been identified as a risk factor on many occasions, without this resulting in African people being warned about the non-sexual risks they and their children face. The status quo has been to claim that health facilities are safe and that almost all HIV transmission is a result of 'unsafe' heterosexual sex.

The above esteemed personages, apparently, "recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission". However, their currently available data, and even their data collection instruments, are designed to diminish the possible contribution of non-sexually transmitted HIV to the most serious epidemics in the world. So they do, as they claim, make 'explicit reference' to non-sexual transmission, but they expect us to believe that it only accounts for a very small proportion of all transmission, about 2.5% for a country such as Kenya.

Whether they are right or wrong, we can only guess. Nosocomial infections, also known as 'hospital acquired infections', are certainly a recognized phenomenon in Western countries. A recent article about the UK health service finds that in one year, 70 people had operations on the wrong part of their body and 161 had foreign objects left inside their body after an operation. But are such data even collected in countries like Kenya, Uganda and Tanzania? Not too often, I suspect. Another article claims that Kenyan doctors are striking because of poor health care conditions; whether that's the real reason they are striking is another matter, but they should know more than anyone about conditions (aside from patients, I guess).

In the US, a man is said to be suing the blood service, alleging that he received HIV contaminated blood and is now HIV positive. He was having a coronary bypass, a kind of operation that is not too common in African countries; but less healthcare is not a solution to the problem of unsafe healthcare. In addition, a pharmaceutical company is recalling products that have been linked to a national outbreak of meningitis that has killed 28 people. Despite protestations from UNAIDS, WHO and the World Bank that this kind of thing hardly ever results in HIV transmission, it is likely that such adverse events are far more common in Africa, where some countries only have 30-40% of the trained personnel they need, with frequent breaks in provision of supplies and equipment vital to ensure adequate infection control.

Aside from Kenyan doctors' apparent disgust at healthcare facility conditions, there are other mentions of possible risks to patients from time to time in the press. Patients in a hospital in Homa Bay (one of the highest prevalence areas in Kenya) have been asked to buy their own medicine before receiving treatment. One source said they had not received 'medical supplies', and that the supply is very erratic. There's mention of surgical blades, gloves and disinfectant. But it is commonplace for pregnant women to bring to the hospital two sets of gloves, razor, cotton wool and other things needed to give birth. Whether they are used or not is unclear.

A district official in Kiteto, Tanzania, has expressed 'concern' over the poor conditions found in some health facilities. Apparently patients have to purchase their own water, but most facilities don't have access to water for cleaning much of the time, let alone drinking water. The article is not clear about exactly how bad conditions are but it sounds like facilities are sometimes not used, which may give people some protection from unsafe healthcare, but at great cost to the health of patients.

The above institutions are much more comfortable with articles such as this: "Tanzania: Unsafe Sex Rampant - Study". The article gives a few snippets from the Demographic and Health Survey, which will probably not be made available to the public in full until the data is at least a couple of years old. But we don't get anything to compare it with, so we don't know how serious it is. We can expect 'unsafe sex' to be 'rampant' among sex workers, but we don't know why so many Tanzanian sex workers are infected with HIV when sex workers from other countries are hardly ever infected unless they have other risks, such as intravenous drug use. And there are many people who are not sex workers, yet they seem to face even higher HIV risks, something WHO, UNAIDS and the World Bank are happy to explain away as 'unsafe sex', without bothering about evidence.

Changing the story from 'there is no problem' to 'the problem is very small' is not a real change. WHO, UNAIDS and the World Bank are still refusing to address the real reasons for exceptionally high rates of HIV transmission in some parts of some countries in Africa, putting it all down to unsafe sexual behavior. But sexual behavior does not now, and has never correlated with HIV prevalence figures. Non-sexual risks have not been properly assessed in high prevalence countries, as if the whole issue is too embarrassing for the HIV industry. But these institutions have failed to have any impact on HIV transmission; what could be more embarrassing than that?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Open letter to Michel Sidibé, Executive Director, UNAIDS, Margaret Chan, DG, WHO, and Jim Kim, President, World Bank

The following letter was sent to the recipients indicated and a copy placed on the Don't Get Stuck With HIV website and blog. The letter received the reply reproduced below the original letter (a PDF copy of which can be found here).

Dear Colleagues,

We commend your organizations’ efforts to treat people infected with HIV and to prevent mother-to-child HIV transmission. Such efforts should be continued and expanded. Unfortunately, that will not be enough to stop almost two million Africans from contracting HIV each year.

This letter is spurred by results released in September 2012 from a national survey in Uganda in 2011. We call your attention to one of the findings: 16% of HIV infected children age 0-5 years had HIV-negative mothers, among children with tested mothers. This is the 4^th national survey in Africa to match the HIV status of children and mothers. In the three previous surveys, Uganda in 2004-05, Swaziland in 2006-07, and Mozambique in 2009, 16%-31% of HIV-positive children had HIV-negative mothers (see survey reports and analyses of raw data for Mozambique and Swaziland).

To help stop HIV transmission through skin-piercing procedures in health care and cosmetic services, we urge your organizations to tell the African public what UNAIDS and WHO already tell UN, including World Bank, employees: “unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections” (p. 9 here), and “avoid having injections unless they are absolutely necessary… Avoid tattooing and ear piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized” (p. 23 here).

Warning the public about blood-borne risks for HIV not only allows people to avoid risks, but also empowers and motivates the public to hold their health caretakers (both formal and informal), providers of cosmetic procedures, and ministries of health to a high standard of safety.

Available evidence suggests that warning people about blood-borne risks could have a significant impact on HIV epidemics. During 2003-07, national surveys in 16 African countries asked people how to prevent HIV. In countries where more people said that avoiding contaminated instruments such as razor blades was a way to prevent HIV infection, people were less likely to be infected (see Figure).

Figure: Percent of adults with HIV vs. percent aware of blood-borne risks

Source: For each country, the percent of adults who say “avoid sharing razors/blades” is the average of percents for men and women from 16 surveys, excluding adults who were not aware of HIV or had been previously tested for HIV, as reported in: J Infect Dev Ctries 2011; 5: 182-198. Percents of adults with HIV (except for DRC and Ethiopia) are for 2009 from: UNAIDS, Report on the Global Epidemic 2010; for DRC and Ethiopia these are for 2007 and 2005, respectively, from national surveys available here.

The World Medical Association’s Declaration of Lisbon on the Rights of the Patient avers that each patient has “the right to the information necessary to make his/her decisions.” We ask you to ensure that your organizations adhere to this principle by emphasizing blood-borne risks in HIV prevention education and by making safety a priority in all programming with health care and cosmetic service providers and institutions.

Faithfully,

Dr. David Gisselquist, Dontgetstuck Collective
John J. Potterat, Independent STD/HIV consultant, jjpotterat [at] earthlink.net
Dr. Deena Class, Global health and development consultant
Simon Collery, Dontgetstuck Collective
Dr. Joseph Sonnabend, JSonnabend [at] btinternet.com
Dr. Janet S. St. Lawrence, Professor Emerita, Mississippi State University
Dr. Mariette Correa, Associate Professor, Tata Institute of Social Sciences, Guwahati, India
Dr. Wallace Dinsmore, Consulting Physician, Royal Victoria Hospital, Belfast
Dr. François Vachon, Emeritus Professor, Denis Diderot University, Paris, France


23 October 2012


Dear Dr Gisselquist and colleagues,

Thank you for the open letter sent to Mr Sidibe, Dr Chan and Dr Kim on 15 October, 2012. We recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission, and advise countries that an effective HIV response should take into account all available data on modes of transmission in the design and implementation of their response.

As part of our commitment to reducing HIV incidence and new HIV infections, both the World Health Organization (WHO) and UNAIDS have produced guidance with unsafe skin-piercing procedures. UNAIDS Prevention Policy Paper, and the WHO Global Health Sector Strategy on HIV/AIDS, 2011-2015 make explicit reference to the importance of preventing unsafe injections, surgical practices and blood transfusions. WHO and UNAIDS advise countries to scale up proven and cost-effective strategies, policies and programmes that are tailored to their actual HIV epidemic and its social, economic and health system context (Know Your Epidemic/Know Your Response).

Recently, WHO's Director-General, Dr Margaret Chan called for action on injection safety. Since this call, a cross-departmental working group has been created to develop a policy document and implementation plan on the safety of all therapeutic injections.

Thank you for raising these issues in the letter and for your efforts in the fight against HIV.

Best regards

Paul de Lay
Deputy Executive Director, Programme UNAIDS
Dr Hiroki Nakatani, Assistant-Director General, HIV.AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases

HIV Interventions: When All Else Fails, Blame the Beneficiaries

I think it was around six years ago that I started to look for something to concentrate on for my Master's degree and I considered choosing something other than HIV. It would have been better if I had done so, because to disagree with mainstream views of HIV is to ensure that you are unlikely to work in the field. But I was distracted by a paper by Eileen Stillwaggon on the roles of co-factors in HIV transmission, such as intestinal parasites, malaria, malnutrition and the like. This was one of the best argued papers I had come across on why we should not view HIV as being entirely a matter of sexual behavior.

Such papers still come out every now and again, and it cheers me to think that one day, people (and by 'people', I mean Africans) may not be blamed for getting infected with HIV through their own stupidity, and as a result of their promiscuity. Epidemiologists may conclude from what they already know, that no disease is entirely independent of lots of other diseases, that HIV may actually be like other diseases in that respect. They may start to believe Africans when they say they have not engaged in 'unsafe' sex, and take a look at other possible co-factors. Perhaps they will even look at non-sexually transmitted HIV and conclude with something more credible than peremptory dismissal.

Jennifer Downs, et al, have published an interesting paper on female urogenital schistosomiasis (FUS) and its association with HIV infection. It was found that women with FUS are four times more likely to be HIV positive. Various kinds of schistosomiasis and other parasitic diseases are endemic in many areas, especially in the authors' area of study, around Lake Victoria. In addition to possibly making women more vulnerable to HIV infection, FUS may also result in women being more likely to transmit HIV. In those infected, it may result in more rapid disease progression.

While FUS is more common in girls and younger women who are not necessarily sexually active, many still have FUS when they become sexually active. Once they are above school-going age they are no longer targets of school-based treatment programs, but this is the time many are becoming sexually active. Women should be treated for this debilitating condition as it can have serious long term consequences. But the fact that it may be associated with HIV infection should by now have attracted the attention even of those who still see diseases as being independent of other diseases, and that includes the vast majority of health and HIV donors.

FUS has not yet received the funding it needs, even though the authors estimate that the cost of controlling the disease may be as little as 32 cents per woman. Compare this to the $60 to $120 per man for the voluntary medical male circumcision (VMMC) program that is running in the very places where schistosomiasis and various other diseases are endemic. For some reason, circumcision is very attractive, despite the fact that the association between lack of circumcision and HIV infection is not particularly large. (However, it is impossible to accurately evaluate circumcision as a risk factor for HIV because the randomized controlled trials used to argue for the VMMC program did not establish how many incident infections during the trial were a result of sexual behavior and how many were a result of some other kind of exposure.)

Attempts at eradicating parasitic and other conditions are not unprecedented. Parker and Allen write about a mass drug administration program that aims to eradicate lymphatic filariasis. But they find that there is a substantial discrepancy between village-level and self-reported surveys of drug uptake, which tend to be low, and official reports of drug uptake, which are high. It is found that many people either don't receive or don't avail of the free drugs, for a variety of reasons. The official figures assure donors that the disease will be eradicated by 2020, which is what they want to hear. But the local figures suggest that eradication will not be possible without some big changes in the way the program is run.

Curiously, the authors remark that "if [parents] reject medication for themselves, then they are likely to reject treatment for their children". I don't doubt that the authors are right, but I have been finding it difficult to understand why most sexually active men in Nyanza,Kenya have been refusing the offer of free circumcision, whereas hundreds of thousands of males in their teens and early twenties have, apparently, been circumcised under the VMMC program. At least one of their parents must have given consent for the younger males to be circumcised.

Parker and Allen note that "context-free, pathogen focused NTD [neglected tropical disease] control is a return to 'magic bullet' medicine, and ignores the fact that vaccines and drugs do not cure neglect or poverty". The same could be said for various HIV interventions, including the VMMC program. They go on to say that "intense competition for funding discourages critical thinking and analysis", which is putting things mildly. Attempts to eradicate various diseases or groups of diseases have a long and unenviable history that includes the history of HIV.

You might think that those responsible for reducing HIV transmission and eliminating various diseases, such as schistosomiasis and lymphatic filariasis, would welcome suggestions as to how they could improve their results. But it seems that some programs report the figures their donors like to hear. If the donors were told the truth they might reduce funding. So there's certainly little to be gained from reporting low and declining uptake and effectiveness. Decades of 'context-free, pathogen focused programs' have shown that it's better to report good news. This is not good news for those suffering from various diseases, nor those at risk of doing so. But, when all else fails, blame the beneficiaries.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

What Few People Say (or Ask) About Circumcision and HIV

This is the last blog post that draws on findings from my visit to Kenya to interview people about HIV and circumcision. We could go on forever mounting an attack on the Voluntary Medical Male Circumcision (VMMC) program, with those in favor mounting a defense. But my main aim was to hear what people thought about HIV and VMMC, why some were convinced and why some were not. And the most stunning finding for me was how little people seem to question the various programs that are presented to them, whether they relate to HIV, health, education or anything else.

While it could be claimed that most people are convinced that circumcision will reduce HIV transmission, most sexually active men seem to be giving it a miss. They make up the most significant group that would face high HIV risk through sexual behavior. The majority of the hundreds of thousands of people that are claimed to have been circumcised under the program are either in their teens or in their early twenties. But they do not tend to face high HIV risk through sexual behavior.

Another group that seems convinced that VMMC will reduce HIV transmission is women. But they, along with most men I talked to, don't seem to be aware that the 'evidence' from various oft cited trials is about female to male transmission, not male to female. Promoters of VMMC say that transmission from males to females will also be reduced because there will be fewer HIV positive men, but they neglect to mention that far more women than men are infected with HIV, even among circumcising populations. In addition, women seemed convinced that circumcision reduces HIV transmission because being circumcised is more hygienic, yet this is not a finding of any research.

A worrying aspect of the association of HIV with hygiene is that many women seem to believe, incorrectly, that they should wash their genitals thoroughly after sex (or before, or both). Research has shown that this tends to increase the risk of infection with HIV and possibly other STIs, and there has even been research into how best to reduce this practice. Penile hygiene is also not so straightforward. Some research has shown that it is better for men to wait a while after coitus and then to wipe with a dry cloth, rather than using water and other agents. This may well be far more effective in reducing HIV transmission than circumcision.

It was shocking to me to find so little doubt about the possible effectiveness of the circumcision program. Sometimes those promoting the program claim that previous HIV prevention interventions have failed or have not worked well enough, even though they need to continue advising people to 'abstain', etc (though this may be a good time to choose more appropriate concepts, ones that people understand). Nobody seems to ask why they should believe that VMMC will work any better than ABC, VCT (Voluntary Testing and Counselling) or various other efforts, or why previous efforts that had so little impact are still being promoted.

Those working on the program are clearly far less convinced about the potential effectiveness of VMMC, though they can be quite defensive. They can cite the various 'advantages' of circumcision, but without the almost religious conviction of people who are not so well educated. But ultimately, they seem to be doing it because they get paid to do so and because they can. It's as if they would immediately get behind a campaign for anything else, should the money be forthcoming.

Sexual behavior change and instances of behavior change were frequently mentioned as ways of avoiding HIV in conjunction with VMMC, particularly condom use. It is clear to people that VMMC on its own is not enough. The head of a clinic that performs circumcisions conceded that behavior change and appropriate advice about genital hygiene may be enough, without circumcision, except for the fact that people do not generally use condoms. But no one questioned the continued need for behavior change if they agreed to be circumcised, nor did they question the need to be circumcised if they did not engage in unsafe sexual behavior.

Several people said they believed HIV was related to poverty, but they didn't ask why poverty reduction was not one of the aims of the VMMC program (or any other large scale HIV program), and only one talked of the need for economic interventions. Those who thought circumcision was 'hygienic' did not ask if access to clean water and adequate sanitation would soon follow, as circumcision without the means for washing would still be completely useless if it was just a matter of hygiene. Similarly, a few associated HIV infection with 'idleness' and several more said it was a matter of unemployment or even boredom. But none asked if creation of employment opportunities was not at least as important as what may only be a slight reduction in HIV transmission.

Although one of the VMMC documents claims that up to one infection could be averted for every 15 circumcisions carried out, the figure during the trials was probably closer to 1/75, so at the community level it's likely to be a lot less effective. But very few raised the issue of methods for HIV positive people to avoid transmitting HIV, even though the VMMC program also circumcises people who are positive and people who don't wish to know their status. We don't have a figure for how many circumcised HIV positive people might result in one or more transmission.

Many people talked about condoms though, perhaps because they were so intent on discussing HIV, they didn't mention their effectiveness in preventing transmission of STIs; only one mentioned condoms as a means of reducing unwanted pregnancy. Perhaps people assumed that the failure of condom promotion programs so far to reduce transmission much is because many people still don't use them, but they didn't raise the question of why people would use them more just because they have been circumcised, or why they should bother being circumcised if condoms work so well.

An interesting question may also be why this campaign seems to be entirely funded by the US, with mostly Americans and American paid people doing the research and implementing the program at all levels. Is there something about American culture that allows such a program to go ahead, with enough public support; or at least, without much effective opposition? One might ask the same question about the ABC (Abstinence, Be faithful, use Condoms) campaign, particularly the version that emphasized abstinence for all, faithfulness for those in a long-term relationship and condoms, but only for those in discordant relationships (where one partner is HIV positive and the other is not).

Both VMMC and ABC sometimes attract similar criticism; for example, would this sort of campaign be carried out in the US and would it work? Circumcision is still quite common in the US among sexually active men, but HIV prevalence is higher than anywhere else in the Western world. ABC (or whatever version they used in the US) failed completely, for HIV, unwanted pregnancy and sexually transmitted infections, which are far less common in many European countries where campaigns resembling ABC or VMMC campaigns have never been considered. Only one person questioned the right of another country to impose this kind of intervention on Kenyans.

My impression is not that the VMMC campaign has failed to persuade people that they should get circumcised. Sadly, I suspect that even a lot of the people who are not lining up to be circumcised think that it really does reduce HIV transmission, they just don't fancy it for themselves. But a lot of parents appear to be giving their consent for their teenagers to be circumcised, so they must have been convinced, whether by the campaign or by their teenagers. But the lack of questioning or debate about VMMC is astounding. In this sense, the campaign resembles many of the HIV campaigns that went before.

Most of the people I spoke to live in terrible conditions and they never asked why circumcision should take priority over decent and safe housing and communities, water and sanitation, accessible and safe healthcare, good education, employment opportunities, infrastructure, facilities for disabled people, and all sorts of other things that are crying out to be addressed. I can not conclude that because people didn't mention any of these that they are therefore not important. But I wonder if what is left unsaid about HIV, circumcision, sexual behavior, health and the rest might also be a lot more important than what is said.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Circumcision and Other Interventions: Is the Real Enemy HIV or Sex?

Much of the HIV related work that has taken place in African countries over the last couple of decades has concentrated almost entirely on sexually transmitted HIV. There were probably measures taken in the 80s and perhaps even in the 90s to reduce transmission through unsafe healthcare and other routes of infection. But these have been discussed less and less, to the point where it is now generally stated that almost all HIV transmission in African countries (but not elsewhere) is a result of unsafe heterosexual sex.

You may think that this bias towards sexual transmission has resulted in significant falls in incidence (yearly rate of new infections) in countries that have received the bulk of HIV funding. But you'd be disappointed. Uganda has always had a special place in the HIV literature because, whatever happened there in the 80s, HIV prevalence dropped and stayed relatively low since some time in the 90s. But in the last six years (specifically, from 2004-05 to 2011) the percent of Ugandan adults with HIV increased from 6.4% to 7.3%. But the increase in the number of infections is much more, because Uganda’s population increased by 24% over that period. Taking into account more people, of which a higher percent are infected, the number of HIV infections in Uganda increased 40% over those 6 years. Uganda is no longer a success story.

In contrast, Burkina Faso is a country where HIV interventions have not been nearly so well reported and celebrated in the international press. Yet the percent of adults with HIV in Burkina Faso fell by almost half over the last 7 years, from 1.8% to 1%. During this period, taking into account population growth, the number of HIV infections dropped by 37%. Another country where prevalence (the percent of adults infected) has dropped in the last 5 years is Zimbabwe, during which time many aid agencies and donors suspended their work in the country. Prevalence has remained stable but very high in Lesotho and Zambia, but it has increased in Ethiopia. Although the percent of adults infected remained stable in Rwanda, the number infected increased with population growth. [The last two paragraphs have been amended as an earlier version contained several errors.]

So could there possibly be something wrong with the behavioral paradigm, the view that almost all HIV is sexually transmitted? This is not to suggest that HIV is never transmitted sexually, but just to raise the question of how much is transmitted sexually and how much is transmitted in other ways, such as through unsafe healthcare and cosmetic practices. These are not popular questions to raise, but they should be raised now that the orthodox view seems to have such little impact on the epidemics on which so much effort and money have been spent.

People I spoke to in Western and Nyanza provinces in Kenya, and most other people I've spoken to, have assured me that HIV is almost always transmitted sexually. They do, when pushed a bit, mention other modes of transmission, but they don't believe these are particularly important. Some will even tell you about how most people have lots of sex with different people all the time, not usually the person you ask, but other people, naturally. Sex is said to be generally unprotected, involving multiple partnerships, and even concurrent partners. There is also said to be a lot of alcohol abuse, which is seen as inevitably leading to sex and HIV transmission.

It is hard to get people off the subject of sex, the sex lives or others, of course. Even some people working for HIV NGOs realize that not all HIV is sexually transmitted, but they haven't time to research the issue and they will not do so unless there is funding available. There is good money in just accepting the behavioral paradigm. Others dismiss non-sexual transmission and say that it has been shown to be insignificant. I met one person who asked how UNAIDS and the HIV industry could believe that most people had the time, opportunity or inclination to have lots of sex with lots of different people and concluded that they had not actually checked, but such insights are rare.

When persuaded to name modes of transmission other than sex and related activities, some people mentioned unsafe healthcare. Some, independently of the issue of unsafe healthcare, said it was not possible to question anything in healthcare facilities, that the people working in them were secretive. But most people referred to such phenomena as if they didn't think they occurred much. One referred to 'negligent' doctors or quacks reusing sterile needles and others talked of 'village' or 'community' doctors (who are often not doctors at all). A traditional birth attendant said that they often don't have enough sterile supplies themselves, and also that some hospitals, such as village hospitals and dispensaries, are not safe.

Few people mentioned that HIV can be transmitted through unsafe cosmetic practices, such as hairdressers, where razors and other skin piercing instruments may be reused without adequate sterilization. One person had even been warned about such a risk at the voluntary counselling and testing clinic (VCT) where he was tested for HIV. However, he lived on the street, neither unsafe healthcare nor unsafe cosmetic practices are likely to the the biggest risks he faces on a day to day basis.

One difference between sexual and non-sexual risks is that the latter are ones that most people would not wish to take, if they knew about them. If sex is risky, that may not be such a disincentive to some people. If they prefer unprotected sex to using a condom they are unlikely to take much notice of advice to use condoms. But it doesn't seem believable that anyone would prefer to receive an injection from a reused, unsterilized needle. It is unlikely that parents would happily see their children having their heads shaved with a razor that had been used on several others, without any sterilization afterwards.

So what about the current Voluntary Medical Male Circumcision program (VMMC)? Is it safe? Healthcare facilities in Kenya are not safe, research has shown this, without any resulting action to improve safety. Research carried out before the VMMC program started made it quite clear that circumcision in health facilities was very unsafe and circumcision carried out in traditional settings was even worse. But rather than improve conditions in health facilities, a parallel health structure was set up with the sole aim of performing circumcisions. The tens of millions of dollars so long denied to health services was made available to a program that does nothing but circumcise men.

Like many parallel or vertical health programs, a lot of effort went into producing publicity materials claiming that VMMC was not just about HIV, and that it was not only beneficial to men. But this was similar to the research produced to show that such a multibillion program is worthwhile: very unconvincing. Of course, not so much convincing is needed now they have their money. VMMC clinics are probably safe. It's just that other types of health facility are at least as unsafe as they were before. Some probably have fewer trained healthcare workers and some are spending a lot more time on circumcisions, which are never urgent, but are very lucrative.

HIV continues to be treated as if it is in some way different from other diseases, with the result that people can continue to suffer from other diseases, often easily prevented or treated, as long as they are subjected to the popular HIV interventions, that almost always target sexual behavior and now include male circumcision. But targeting HIV as if it is exceptional among diseases has, by and large, failed. If that is because HIV is not always sexually transmitted, male circumcision programs will also fail to have much long term impact on transmission rates. It's almost as if reducing HIV transmission is not really a priority of the VMMC and broader HIV industry.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Circumcision: Lake Victoria Overrun by Red Herrings and Cod

This is the fifth post where I summarize another group of findings from my recent visit to Nyanza and Western Provinces in Kenya, asking people about HIV and circumcision. The first, second, third and fourth are all available and the complete findings will also be made available in due course.

HIV is said (by UNAIDS, WHO and various other institutions) to be almost always transmitted sexually in African countries. Therefore, in the highest prevalence parts of African countries, it must be wondered what kind of sex explains such very high rates. For example, in parts of Kenya rates are very low, such as Northeastern Province. In others, rates are high, such as parts of Nyanza and Nairobi. Among the Luo population of Nyanza, HIV prevalence is was said to stand at 20.2% in the 2008 Demographic and Health Survey (DHS), compared to 6.3% in Kenya as a whole (and even lower among the Kisii and Kuria tribes of Nyanza. But Luos don't appear to have any idea why HIV prevalence should be so high among their tribe, compared to other tribes.

A common suggestion is promiscuity. The DHS does find that some 'unsafe' sex indicators are higher for Luos, but some are lower. And overall, Luo sexual behavior does not seem to explain such inordinately high HIV rates. Yet the head of a clinic that carries out circumcisions simply listed promiscuity, along with various other factors that are often cited for high prevalence in other countries. He did not suggest that levels of promiscuity are higher among Luos, or that their sexual behavior is in any way more risky. Nor did he explain why HIV prevalence does not correlate very clearly with sexual behavior, in Kenya or in any other country.

One community leader, when told that promiscuity can also be common among non-Luos (and non-Africans) without HIV prevalence being high, said that Luos have more sex, do not practice circumcision and do not use condoms. A former public health researcher does not believe that circumcision is the reason for high HIV prevalence but can offer no explanation as to why rates are so high among Luos. A high school student said that Luos may not all be promiscuous but a lot of poor people, mainly females, have sex in exchange for money. Others talk about promiscuity as a reason for high HIV prevalence in general, not just among Luos.

The issue of widow inheritance comes up several times but no one can say how common the practice is. One woman talked of lots of women losing their husbands and being inherited, another says that widow inheritance is 'very common'. A pastor of the Nomiya Church said that if you inherit you will be infected and pass the virus on, although his church also permits this practice. The pastor also mentioned 'traditions' in passing and said that some people think HIV is caused by ‘chira’, taboo. He said that some practices of traditional medicine may also risk transmitting HIV. But he believes HIV transmission is mostly sexual.

A college student said that some males ‘get involved’ with married women, especially widows who have a lot of money, but he does not mention the practice of widow inheritance. However, a former public health researcher said that widow inheritance is no longer practiced much, except perhaps in remote areas, and is unlikely to be an important factor in HIV transmission. He feels that the same applies to other traditional and tribal practices.

One student suggested that younger females have sex with older males for money, and that this is a result of poverty, but that not many younger males do this. Another student said that Luo teenagers can ‘walk with girls’ (a euphemism, also used by someone who was told to avoid 'women who walk around') and be infected with HIV that way. A religious leader and a traditional Luo leader said that some women have extramarital sex in exchange for money, both adding that it was as a result of poverty. A market trader said that Luo people like ‘raha’ (enjoyment, happiness) and translated this as ‘prostitution’. She said there were high rates of unemployment among young people and a shortage of money, leading to transactional sex.

A man who performs circumcisions remarked that most people in high HIV prevalence areas were very poor and that some may have sex as there is nothing else to do. Perhaps this can be compared to a discussion I attended among HIV peer educators in a rural area of Western Province, who were being taught that idleness leads to HIV transmission because idle people are tempted to engage in unprotected sex. But more commonly, transactional sex was said to be a result of poverty, to which a lot of HIV transmission is attributed.

The phenomenon of ‘jaboya’ is often cited as a reason for high HIV prevalence among Luos who are involved in the fishing trade. It is said that fishermen require women to sleep with them if they want to get the best fish to sell. A public health researcher mentioned jaboya as a possible reason for high prevalence in some villages but also pointed out that HIV prevalence can be just as high in villages that have little to do with the fishing industry. But a recent report on HIV prevalence by occupation in Uganda found that HIV prevalence is not exceptionally high among fishermen (or transport workers, who have had the collective finger pointed at them since the early days of HIV).

A religious leader also cited the behavior of fishermen, saying that they ‘lured’ women with fish and money and engaged in transactional sex. A market trader, not herself involved in selling fish, said that young ladies like fishermen and that they have sex in exchange for fish. But the issue of jaboya was hyped by the media some years ago and there seems to be very little real research into the phenomenon, with citations all appearing to lead to the one, somewhat questionable, source.

Polygamy is a popular hobby horse in the HIV industry, although much of the evidence suggests that HIV prevalence is often lower in polygamous societies. A teenager from the Kisii tribe said he thought HIV prevalence was higher among Luos than Kisii because the former practiced polygamy and the latter did not. A health researcher suggested this as a possible reason for high HIV prevalence among Luos and a community leader said that HIV can be ‘brought into the house’ (a sort of euphemism) in a polygamous family unit, but this was not just in relation to Luos. She later said that housegirls are often the ones who ‘bring HIV into the house’. Housegirls have been blamed for many things in the past, including HIV, although there is no evidence that prevalence is exceptionally high among this group (despite the fact that their employment and living conditions are often appalling).

There are lots of posited explanations for high HIV prevalence among Luos, but many are the same explanations for high prevalence among other groups. The problem is that 'unsafe' sexual behavior (paid or unpaid) does not always result in high rates of HIV transmission, so why should it do so in some parts of some African countries? Other posited explanations are not exclusive to high HIV prevalence groups, do not appear, under scrutiny, to explain anything, or they are not widespread enough to account for very high rates of transmission.

Voluntary Medical Male Circumcision (VMMC) is being sold to Luos as a viable way of reducing sexual transmission of HIV, though they are being told that almost all transmission is sexual. If HIV transmission is almost always sexual, it needs to be shown why it is so high among some groups and not others, and what kind of sexual behavior, exactly, is involved. Otherwise, the industry may have to carry out some much needed research into non-sexual transmission, at least to rule it out, rather than to continue dogmatically denying it exists, without any evidence whatsoever.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Circumcision: Neither Right Nor Wrong, Just Funded

Aside from many people in Nyanza that I spoke to being convinced that circumcision reduces HIV transmission, some also mentioned lack of clarity, information bias and/or lack of information, or showed signs of being confused about the VMMC program (Voluntary Medical Male Circumcision). Some said they were completely influenced by the mainstream view about HIV being almost always transmitted sexually in African countries, and that therefore they believed VMMC could be effective. They agreed that there was room for doubt, but also said that they did not have the scope for questioning the mainstream view and they were aware that many funding sources require a strict adherence to this view.

One person working for the program said he was obliged to find and disseminate positive things about VMMC and ignore or quash negative beliefs. Another, who worked in public health, said he and others in the field had to work on programs that would get funding. VMMC gets a lot of funding, as do many projects that assume that HIV is almost always transmitted through heterosexual sex in African countries. But projects to improve health systems, water and sanitation, nutrition or neglected tropical diseases will not generally get funding, unless they can be shown to relate to HIV transmission in some way. Even programs that have no connection with health, education or the like are often required to show how many HIV positive people benefit or how many ‘AIDS orphans’ will benefit, etc.

Only one person pointed out that circumcision does not appear to protect Americans, yet the funding for VMMC all comes from the US. He feels the program is being forced on Kenyans at all costs and was also aware that HIV prevalence is low in Europe, where circumcision is generally not common.

A traditional Luo leader feels that he and other senior Luos were not given access to all the information available when they were being lobbied to get behind the program, although he was the only respondent to be clearly aware that HIV prevalence is as high among circumcised as uncircumcised Luos. Another traditional Luo leader felt that he and his fellow Luos were not always given clear information and that important issues may not have been addressed, such as the question of why many people in other circumcising populations are HIV positive. He still believes the program can work but also feels that progress needs to be evaluated on an ongoing basis and that adjustments may need to be made over the duration of the intervention.

A senior government officer had given the matter of sexually transmitted HIV a lot of thought and, understanding the connection between circumcision and sexual transmission, did not feel it had ever been explained why HIV prevalence was so high among Luos. He said he didn't think Luo women had 'more sex' than women from other tribes. In contrast, another senior government officer accepted the mainstream view about HIV and fully supports VMMC. A religious leader in Nairobi appeared to know little about HIV, despite working with sex workers, refugees and others thought to be at elevated risk of being infected.

There are several striking examples of gaps and imbalances in the kind of information people appear to have had access to. A local government leader from a circumcising tribe said there are a lot of misconceptions about the sort of protection circumcision gives and that some women think there are no HIV related risks with circumcised men, that they are ‘safe’. A market trader, who believes VMMC will be very effective at reducing HIV transmission, also believes (incorrectly) that HIV prevalence is always lower in areas where circumcision is widely practiced. A pastor I spoke to seemed relatively well informed about HIV, but he had trouble separating information from spiritual guidance. A traditional birth attendant, who has also worked as a community health worker, says she is confused about whether circumcision really reduces HIV transmission and would like to know where the idea comes from. She also says that her clients and community understand little about HIV.

A ‘street kid’ was encouraged to be circumcised by his girlfriend, who believes it ‘prevents’ HIV, but neither seem to realize that it is only thought to reduce transmission from females to males. Although this man was informed about non-sexual as well as sexual risks, he was not aware that circumcision only reduces transmission through sex. Another ‘street kid’ had been persuaded to have the operation and was told that it would be more painful if he waited till he was older, but he was already 15 and the claim that it would be more painful sounds quite dubious. People who are considered to be too sick to be circumcised immediately are supposed to be treated first, and then circumcised later. But it seems that people who live in conditions where circumcision would always involve risks for them are not so lucky.

Many spoke of a need for further research, for example, a former public health worker who does not oppose VMMC but does not think it will work very well. He said the evidence for the effectiveness of circumcision in reducing HIV transmission is not strong and that there has been little research into non-sexual modes of transmission, including unsafe healthcare. Someone involved in the program agreed that evidence is weak but said that it is getting stronger as time goes by and that in scaling up VMMC they are also seeking new evidence. The head of a clinic that performs a lot of circumcisions also said the evidence is not that strong and that the level of protection from circumcision may be lower outside of a randomized controlled trial, but that he does not yet know what level of protection can be expected as they are only four years into a ten year program. However, he also said the decision to concentrate on circumcision and less on any other HIV and health interventions was one taken by donors, not by people working in healthcare.

Several people asserted that what they had been told about VMMC was ‘science’. A religious leader said we should proceed with VMMC because research has shown that it works. A senior government official describes the 60% protection as ‘scientifically proven’. But a senior public health expert working on the program did not emphasize scientific certainty at all, saying that ‘you don’t know until you try it’ and that this is always the way in science and public health. He did emphasize agreement among normative agencies, donors and the great majority of scientists, though. He pointed to the evidence that is being gathered about the effectiveness of VMMC since the program started, rather than the evidence from several randomized controlled trials.

People who refer to ‘scientific’ and ‘official’ findings are often thinking of three randomized controlled trials that purport to show that circumcision reduces sexual HIV transmission. But they are unaware that it was not shown that all incident infections during the trial were sexually transmitted. A number of people seem to think that circumcision reduces HIV transmission per se, although it is only thought to reduce transmission from women to men. No one raised the possibility that the operation may not reduce, and may even increase transmission, from men to women. The potentially dangerous fact that HIV positive people can be circumcised under the program, whether they know their status or not, was not raised except by someone working for the program.

Sometimes the VMMC propaganda machinery is very efficient. People I spoke to do not adhere to the ‘no risk’ myth about circumcision, the belief that once you are circumcised you don’t need to take other precautions. On the contrary, most people mentioned the 60% figure and added that other precautions were still necessary, often without any further questioning. Some do attribute the ‘no risk’ myth to others, however. But whether circumcised or not, many are clear that the effectiveness of VMMC still depends on individual sexual behavior.

Despite this, one man who works in a VMMC clinic does not seem to believe that people will take behavior change related precautions once they are circumcised, especially as behavior change communication does not seem to have had much impact in the past. He believes that VMMC may provide some protection even to those who do not use condoms, and (somewhat inexplicably) that the combining of circumcision with other precautions will work better than they did before VMMC was implemented.

Only two people talked of deliberate transmission of HIV. The first said that HIV positive people did not want to die alone and that they would ‘donate’ their HIV to as many people as possible. She also believes that there are several signs by which one can tell a person is HIV positive. She thinks VMMC will help but that HIV positive people need to be more careful. The second is a traditional birth attendant and she also uses the term ‘donate’, saying that this is sometimes a revenge for being infected. Apparently associating being HIV positive with particular behaviors, she said that HIV positive people drink a lot in bars as they ‘donate’ HIV.

I was surprised to hear a health worker on the VMMC program saying that women on antiretrovirals can be the most desirable in a community as they look so healthy and fat. But a senior government officer said almost the same thing when asked to give her opinion on HIV and circumcision. A mother and housekeeper said that if someone is thin and then receives ARVs, they get fatter and change in other ways too. But she also said that you can tell when someone is infected because they have spots and boils, different skin color and that the part of the face next to the mouth is fatter.

Billions of dollars have been poured into HIV, although transmission rates (incidence) do not seem to have changed much in the last ten years in Kenya (or even Tanzania or Uganda). So people can be expected to be familiar with the HIV flavor of the month, which in Nyanza right now is circumcision (VMMC). Gone are the days when the first thing some would talk about is ABC (Abstain, Be faithful, use Condoms) or even VCT (Voluntary Testing and Counselling). Abstinence was mentioned twice, condoms were mentioned perhaps because they are a focus of the circumcision program, but being faithful was barely mentioned and being tested was only mentioned once. No one used the term 'ABC' at all.

Various elements of the VMMC party line are repeated with almost religious fervor by most people when you ask them about their views on HIV and circumcision. Even Luos repeat the various posited explanations of exceptionally high HIV prevalence in their own tribe, though these explanations are both insulting and unsupported by evidence. Many object that HIV prevalence can also be high in circumcising populations but, despite being given no adequate response to this, an alarming number seem to have given their consent (arguably 'informed' consent) for their teenage boys to be circumcised. It seems that in the HIV industry there is no right and wrong, only funded and unfunded.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]