More junk science underestimating HIV from medical injections

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

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

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

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

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

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

Several obvious problems with the estimate are as follows:

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

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

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

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

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

References

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

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

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

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

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

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

HIV in Namibia: What You Don't Seek, You Won't Find

There was no mention of HIV in Namibia's 1992 Demographic and Health Survey and AIDS was only mentioned in passing. HIV prevalence had more than doubled since 1990, from 1.2% to 2.6%. But by 2000, when their second DHS was carried out, prevalence is estimated to have reached 14%, five times higher in less than a decade. So what areas of HIV had Namibia addressed during this time? The following table is from the 2000 DHS (p155, Table 11.1) :

Ways to avoid HIV/AIDS	Women	Men
Does not know AIDS or if it can be avoided	7.9	4.0
Believes no way to avoid	4.0	2.3
Does not know specific way	0.3	0.0
Abstain from sex	34.7	40.5
Use condoms	80.9	87.0
Have only one sexual partner	31.0	28.5
Avoid multiple partners	7.4	10.5
Avoid sex with prostitutes	1.0	3.3
Avoid sex with persons who have many partners	1.6	2.5
Avoid sex with homosexuals	0.2	0.3
Avoid blood transfusions	1.3	1.0
Avoid injections	0.8	0.6
Avoid sex with IV drug users	0.6	0.5
Avoid sharing razors/blades	2.2	2.6
Other including avoiding kissing/mosquito bites/traditional healer	1.8	1.6
Total	6,755	2,954

Aside from over 80% of people knowing about using condoms against HIV, which is good, knowledge about other ways of avoiding infection, even sexually transmitted HIV, ranges from poor to negligible. But the fact that less than 1% of people know that unsafe injections can transmit HIV is extremely worrying, considering risks from unsafe injections was well known at this time. More people are aware of the risk of transmission from razor blades than the risk of blood transfusions.

Even Jacques Pepin, who strenuously denies a significant role for unsafe healthcare in high HIV prevalence African countries, admits that 5% of HIV may have been transmitted via these routes globally in 2000, which means the contribution must have been far higher in countries with low safety standards and high HIV transmission rates, such as Namibia. Strangely, Pepin claims that safety in health facilities has improved so much in the ten years from 2000 to 2010 that "unsafe injections caused between 16,939 and 33,877 HIV infections" globally in 2010.

It is not very clear where Pepin got all his figures to carry out this estimate but there were an estimated 1.6m new HIV infections in sub-Saharan Africa in 2012 (compared to 2.6m in 2001). Does it seem credible that something in the region of 1.5% of all new infections globally (33,877 as a percentage of 2.3m new infections in UNAIDS' 2013 Global Report), at the most, were transmitted through unsafe injections? It sounds like Pepin was trying to find a figure that concurs with UNAIDS' Modes of Transmission Analyses, which have been claiming that the contribution of unsafe injections in African countries has been at that very low level since they started carrying out these analyses.

The Modes of Transmission model is so flawed that it overestimates heterosexual HIV transmission by several hundred percent, leaving the majority of transmissions unexplained. Therefore, their minute figure for transmission through reused syringes and other forms of unsafe healthcare could not possibly be correct, and seems to have been arrived at by overestimating heterosexual transmission and then claiming that only the remaining infections, a very small percentage, could be a result of unsafe healthcare.

Neither Pepin nor UNAIDS appear to have bothered investigating conditions in health facilities, possible outbreaks of healthcare transmitted HIV, infections among people who have never had sex, infections among people who only engage in 'safe' sex, infections in mothers who may have been infected by their infants and infections in infants whose mothers are HIV negative. If Pepin comes up with the same sort of figure as UNAIDS then his model is likely to be as flawed as theirs.

Namibia's 2006-07 DHS finds that knowledge about 'unsafe' sex is high but this has had little impact on sexual behavior, nor on HIV transmission. So, no surprise there. The report blandly states that "HIV is transmitted among adults primarily through heterosexual contact between an infected partner and a non-infected partner" (which is what all DHS reports say, along with UNAIDS and other international institutions).

Report after report comes out on 'knowledge, attitude and practices' (KAP) from high prevalence country after country, and various well funded national and international institutions never seem to wonder if reducing HIV transmission is not merely about how much people know about sex, their attitudes towards sexual transmission and their sexual practices. For how long can this go on?

There's a small amount of data in the 2006-07 DHS about whether people had medical injections and whether they remember if the person administering the injection saw the injecting equipment being taken out of a new packet, but there are no corresponding figures for HIV prevalence in relation to receipt of medical injections. It is concluded that most public and private facilities, at least 90%, practice safe injections, but that the lowest level of safe injections was found for women attending some types of private facility, at 49%; not so reassuring.

Figures for the next DHS (2013) are not yet available, but from the list of data being collected there doesn't seem to be any new attention paid to non-sexual transmission of HIV, especially through injecting equipment reuse and other forms of unsafe healthcare. If you don't investigate, you don't need to deny finding the incriminating figures. This has worked for UNAIDS, but not for Namibia, or for any other country with serious HIV epidemics.

[For more about HIV from unsafe healthcare, visit our Healthcare Risks for HIV pages.]

Infinite Regress of Expert Opinion On the Behavioral Myth of HIV in Africa

In an otherwise interesting article by Paul Sharp and Beatrice Hahn about the origins of HIV, the authors make a familiar, but poorly supported claim: that "AIDS is...primarily a sexually transmitted disease". I always wonder if citations for such claims will actually present evidence, or if they just lead to a blind alley, eventually.

Sharp and Hahn cite a paper by Myron Cohen et al and one by Florian Hladik and M. Juliana McElrath. But Cohen et al only refer to Haldik and a lengthy report by UNAIDS from last year, which doesn't cite any supporting evidence. It says: "The vast majority of people newly infected with HIV in sub-Saharan Africa are infected during unprotected heterosexual intercourse (including paid sex) and onward transmission of HIV to newborns and breastfed babies. Having unprotected sex with multiple partners remains the greatest risk factor for HIV in this region."

This completes the mantra about 80% of HIV transmission being a result of heterosexual intercourse and much of the remaining being a result of mother to child transmission.

Hladik and McElrath refer to another report by UNAIDS, this time from 2007. Despite the constant repetition of an assumption about heterosexual transmission, I could not find any supporting citations. UNAIDS do frequently refer to their 'Modes of Transmission' surveys, but these are hopelessly flawed and do not support the assumption. Hladik et al decide that, although transmission via infected blood is possible such a phenomenon is beyond the scope of their review.

I could chase around and look at various UNAIDS publications that propagate what has become one of the most enduring myths about HIV transmission in Africa, that it is almost always a result of heterosexual sex, but there are too many such publications, and too many of them just cite other UNAIDS publications. One might hope for peer-reviewed articles, like the ones cited above, to break the vicious circle, the incestuous practice of experts citing other experts until they have created a web of questionable views that are then used to spawn global policies. But years of reading such documents has not led to any clear and independent assessment of the relative contribution of sexual and non-sexual modes of transmission to the most serious HIV epidemics. If I ever stumble upon such an assessment I shall certainly share it widely.

But I don't believe evidence will ever be produced to show that sex explains almost all HIV transmission in Africa, not even from all the experts and senior bureaucrats who have made it their life's work to cling to this view, because it simply is not true. There is too much evidence that HIV has been transmitted through unsafe healthcare and various other non-sexual routes. But UNAIDS have resolutely refused to investigate any of this evidence.

[For more about non-sexually transmitted HIV, view our Healthcare Risks for HIV and Cosmetic Risks for HIV pages. For more about some of the terrible consequences of adhering to this behavioral myth of HIV transmission in Africa, see our Male Circumcision and Depo-Provera (DMPA, hormonal birth control) pages.]

Age-disparate relationships do not drive HIV in young women. KwaZulu-Natal, SA

I commented on this back in March when it was reported at a conference. Now the paper has been published (though it is not available free of charge). It concludes: "In this rural KwaZulu-Natal setting with very high HIV incidence, partner age-disparity did not predict HIV acquisition amongst young women. Campaigns to reduce age-disparate sexual relationships may not be a cost-effective use of HIV-prevention resources in this community."

The HIV industry likes to believe that, although HIV is almost always transmitted through 'unsafe' heterosexual sex in African countries, unlike in other countries, it is men's behavior that is most responsible. This supports their 'all men are bastards, especially older men, and all women are victims, especially younger women' mentality.

It's good timing. After 23 years of monitoring their epidemic in South Africa, HIV experts have seen HIV prevalence increase from less than 1% to almost 30% in that time, and stagnating at over 25% for about the last 10 years. KwaZulu-Natal is the worst affected province, with HIV prevalence in some districts reaching 40% among antenatal clinic attendees.

Perhaps a little less emphasis on sexual behavior and a little more emphasis on non-sexual risks, such as unsafe healthcare, traditional and cosmetic practices, may shed some light on what is driving the epidemic and why efforts to influence HIV transmission in any way seemed to have failed thus far.

[For more about non-sexual HIV transmission via unsafe healthcare, traditional and cosmetic practices, and how to protect yourself from these, have a look at some of our more detailed pages.]

GlaxoSmithKline: "How Modern Clinical Trials are Carried Out"

"We would need further details to investigate what actually took place, but the practices outlined certainly don’t reflect how modern clinical trials are carried out. We conduct our trials to the same high scientific and ethical standards, no matter where in the world they are run."

That's a comment from a GlaxoSmithKline spokesperson following the discovery of mass graves of an estimated 800 children in Ireland, who are thought to have died while taking part in 'secret' clinical trials, for which there is no evidence informed consent was ever given. That's a huge number of deaths, by any standards. It is to be wondered how many deaths (and injuries) it took before the trials were stopped.

It would be nice to think that the GSK spokesperson is right, that such things could never happen today. But there's a whole list of unethical practices in Wikipedia that GSK have been involved in, and those are just the more recent cases. And what about their current collaboration with the Gates Foundation to develop a malaria vaccine? Such a vaccine would be a godsend, but who is keeping an eye on them, given their record?

I don't doubt that such things no longer happen in Ireland, nor in other Western countries. But unethical practices in African countries are certainly not a thing of the past.

The Don't Get Stuck With HIV site has a section on DepoProvera (DMPA) hormonal contraceptive, which evidence suggests may increase infection with HIV among those using, and onward transmission by those using the method. Also on this site David Gisselquist has written about the unethical behavior of health professionals who have failed to investigate or act in any way on evidence that infants and adults may have been infected with HIV through unsafe healthcare.

WHO have been dragging their feet over unsafe healthcare, especially unsafe injections through reuse of injecting equipment, use of DepoProvera in HIV endemic countries and various non-sexual modes of HIV transmission. There are also the mass male circumcision campaigns, which are based on lies about research that was carried out in Kenya, South Africa and Uganda. It has never been explained how people who seroconverted during these trials were infected with HIV, it was just claimed that they must have had unsafe sex. Though many of the men did not have any obvious sexual risks, non-sexual risks were not considered, including the circumcision operation itself.

The list of serious ethical breeches goes on. Some participants taking part in the circumcision trials were not told they were infected with HIV, and were followed to see how long it would take for them to infect their partners, who also weren't told they were at risk. This resembles the Tuskegee and Guatemala Syphilis 'Experiments', which also ended in the 1960s. Yet mass male circumcision campaigns are ongoing and extremely well funded, despite not having anything like the rate of takeup anticipated by those making a lot of money from carrying out the operations.

There has been some secrecy surrounding DepoProvera, and a lot of data about mass male circumcision may have been collected but never released, but much of the data about these issues is readily available to anyone with an internet connection. Like the results of the Irish trials, much of the research was published in "prestigious medical journals". But I assume this is not what GSK is referring to when they talk about 'modern clinical trials'?

HIV Transmission Via Medical Injections in Kenya - Significant Risk

Congratulations to Kenya on being one of the first African countries with a serious HIV epidemic to investigate the role of unsafe healthcare and reuse of injecting equipment in transmitting HIV. The study finds that "Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months."

But these findings make the conclusion of the article all the more striking: "Injection preference [my emphasis] may contribute to high rates of injections in Kenya." If someone is infected with HIV as a result of receiving an injection, then it is the behavior of the health care practitioner that is at fault, not the 'preference' of the patient. Health facilities make more money from procedures such as injections than they do from just giving advice or handing out prescriptions, so there may be good reasons why patients 'prefer' injections; they may have been led to believe that injections are 'better'. I'd also be surprised if mere patient preference made much difference to the kind of treatment a patient received in Kenya or elsewhere in East Africa.

Those providing health services need to take responsibility for healthcare associated HIV transmission, and that includes Ministries of Health, professional bodies, and also the WHO, UNAIDS, CDC and other parties who have dominated health and HIV policy in high HIV prevalence countries for decades. Reuse of syringes, needles and other skin piercing equipment carries a very high risk of transmission of HIV, hepatitis and other pathogens. It is not enough to blame patients for their 'preferences'. Practitioners can decide what treatment a patient needs and what is the best means of administering it, if that means is available to them.

The paper recommends that "community- and facility-based injection safety strategies be integrated in disease prevention programs". If this is UN-speak for the need to accept that HIV is frequently transmitted through unsafe healthcare and these practices need to stop, then I wholeheartedly agree. This is more than thirty years too late, but it's good to hear the very mention of non-sexually transmitted HIV in the form of unsafe healthcare being taken seriously in a peer-reviewed journal. I look forward to hearing of other high HIV prevalence countries making the same 'discovery' and publicizing it, and also taking steps to reducing such transmission risks.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don't Get Stuck With HIV site's Healthcare Risks for HIV pages.]

It's not Condoms that are Failing to Protect Against HIV, it's UNAIDS

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

At the beginning of this month, David Gisselquist took a careful look at UNAIDS' 'Modes of Transmission' model and found it seriously lacking, grossly overestimating HIV transmission among couples in long term relationships in Malawi. As a result of this flaw, the model gives results which appear to support the extremely racist view that most Africans in high HIV prevalence countries, male and female, engage in a lot of unsafe sex, and mainly sex with people other than their partners.

David shows how the Modes of Transmission model currently estimates that 81% of Malawi's 95,000 new HIV infections were accounted for by spousal transmission. If you remove the flaw, the percentage goes down to 20%, leaving 60% of all infections unaccounted for by the model (non-sexual transmissions from mother to child make up much of the remainder). How were all those other people infected, including the women who are said to have infected their babies?

It is very likely that a substantial number of HIV infections in Malawi and other high prevalence countries are a result of non-sexual transmission, such as through unsafe healthcare, cosmetic procedures and traditional practices. The much lauded 'ABC' (Abstain, Be faithful, use Condoms) approach to HIV prevention does not work, not because many Africans actually live up to the stereotypical 'all men are bastards, all women are hapless victims', but because HIV is not always transmitted through heterosexual sex.

Consider condoms, which are a great technology for reducing unplanned pregnancies, many sexually transmitted infections and sexually transmitted HIV, through anal and vaginal intercourse. But a number of surveys have found that HIV prevalence is very high among those who use condoms. Indeed, prevalence is often higher among those who at least sometimes use condoms than among those who never use them. The following chart is from the relevant Demographic and Health Survey for four countries.

In some cases, HIV prevalence is 50% higher among those who sometimes use condoms than among those who never use them, sometimes 100%. Shocking? Only if you think HIV transmission in high prevalence African countries is all about sex. Consider another set of figures, this time for condom use at last sexual intercourse in past 12 months. The figures for those who have not had sex in the past 12 months also raise questions (data from DHS surveys). You could suggest that people are not honest, or that people who are infected are 'abstaining', but it is far more vital to figure out exactly how people are being infected in order to prevent further infections.

Why are HIV prevalence figures so much higher among people who say they sometimes use condoms? I can only tell you what I think; condom use is completely irrelevant to non-sexually transmitted HIV. That sounds obvious, but UNAIDS insist that almost all transmission is through heterosexual sex, yet they stand by figures like these. It is not possible for HIV prevalence to be so much lower among those who never use condoms if almost all HIV transmission is sexual. But there may be an explanation for why those who sometimes use condoms seem so much more likely to be infected.

HIV prevalence is often highest among wealthier, urban dwelling, employed, female, better educated people who live in wealthier countries that have reasonable access to reproductive healthcare services, a relatively low population density and sometimes a higher urban population (but not always). People who answer that description, people who can tick at least some of those boxes (some of the factors are interdependent), it seems, are also more likely to use condoms.

So it is not a case of people with the above characteristics using condoms, yet still being more likely to be infected with HIV, but rather a case of those same people being more likely to be infected with HIV through unsafe healthcare or some other non-sexual route. Once you challenge the sexual behavior paradigm the rest is clear: condoms are irrelevant to non-sexual HIV transmission. It only sounds unintuitive if you keep clinging to the sexist, racist and extremely dangerous reflex about sexual behavior, so beloved by UNAIDS, WHO, CDC, PEPFAR, the Gates Foundation and various universities that have been prominent in the HIV industry.

Given what we so often hear about HIV being inextricably linked with poverty, unemployment, lack of education, isolation, poor access to health services, etc, it is worth emphasizing that the virus may often be more closely linked to the opposite of these factors. Of course, all of these factors are abhorrent and it should be the aim of every wealthy country to ensure that such conditions are alleviated. But if HIV is being transmitted through unsafe healthcare and other routes, all healthcare development must be SAFE healthcare, all HIV education must include information about non-sexual transmission, all employment 

and environments must exclude risks of bloodborne transmission of HIV, as much as possible.

So first we need to recognize that HIV is not solely transmitted through 'unsafe' sex and that it can be transmitted, perhaps far more easily, through unsafe healthcare, cosmetic procedures and traditional practices. ABC 'strategies' do not work because HIV transmission is not all about sex, not because Africans are too careless, promiscuous or ignorant (or even 'disempowered') to follow its patronizing advice. Safe sex has its place, but safe healthcare is a far more urgent issue in high HIV prevalence African countries right now. It's not condoms that are failing to protect people against HIV, but the intransigence of UNAIDS and the rest of the HIV industry.