Wednesday, July 30, 2014

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else's blood, or how to avoid this.

The Don't Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else's blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don't Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don't know there is a risk and they don't know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO's 'Tool C', also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

"Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface...

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub...

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections...

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle...

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes...

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container."

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and 'traditional' practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.


Monday, July 28, 2014

Seek and you shall Find: Evidence in Support of HIV Drug Sustainability

A recent piece of research claims to find that mass male circumcision programs do not result in 'risk compensation', the idea that some HIV interventions can result in an increase in 'risky' behavior, such as sex without condoms. Happily for those aggressively promoting mass male circumcision, they say they found no evidence of risk behavior. Whether they found evidence that it doesn't occur, rather than failing to find evidence that it does occur, is another matter.

And a meta-analysis of "every study that has looked at the sexual behaviour of people after starting HIV treatment" has found no evidence of 'risk compensation'. Most of the studies took place in African countries. These results must have found a welcoming audience at the HIV industry's annual back-slapping event that has just finished in Melbourne.

But these findings may suggest something very significant that the researchers have not mentioned: perhaps HIV positive people are nowhere near as promiscuous, careless and uncaring as they are depicted as being by the HIV industry thus far.

It is not known what proportion of HIV transmission is a result of sexual intercourse and what proportion is a result of other modes of transmission, such as exposure to contaminated medical instruments, unsafe cosmetic or traditional practices.

The assumption that most transmission is a result of sex is a prejudice, rather than an empirical finding. The assumption that transmission through various non-sexual routes is low is a result of not looking for evidence that would demonstrate such transmission and ignoring any evidence that comes to light, which it usually does inadvertently.

Those promoting mass male circumcision and other revenue streams do seem to be inordinately blessed when it comes to finding 'evidence' that the intervention is safe, acceptable, effective and worthy of the hundreds of millions that has been spent, and the billions that has been earmarked for moving from adult and child circumcision to include infant circumcision, the latter being a far more sustainable proposition.

Now that so much money can be made from various mass HIV drug administration strategies, such as pre-exposure prophylaxis, early treatment, treatment as prevention, treating HIV positive pregnant women for life (as opposed to a shorter course of treatment), etc, it seems unlikely that any of the big funders will wish to put much money into finding out how people in high prevalence countries are infected in the first place, and aiming to prevent such infections from occurring.

Of course, like infant circumcision, allowing a substantial number of people to continue to be infected with HIV is far more sustainable than aiming for the industry's claimed goal of virtually eliminating HIV by 2030. A steady stream of new infections from the worst epidemics should keep the industry afloat for at least a few more decades, and perhaps even ensure their survival for the rest of the century.


Friday, July 25, 2014

Kenya's HIV Prevention Revolution: Beating Swords into...Condoms

Kenya's recently published 'HIV Prevention Revolution Road Map - Count Down to 2030' presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country's epidemic is.
Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned 'King of Condoms', with a paper crown on his head, demonstrating to the country's first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don't see that as an instance of crass infantilization? Perhaps they don't find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed 'Modes of Transmission' spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn't we start collecting empirical data to guide future efforts?


Thursday, July 24, 2014

Why 'Reducing HIV Transmission' Must Never be an Excuse for Genital Mutilation

The English Guardian has put together figures for female genital mutilation (FGM) and the top ten are Somalia, Guinea, Djibouti, Egypt, Sierra Leone, Mali, Sudan, Eritrea, Gambia and Burkina Faso. But the top ten for HIV that I have been looking at recently are Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Zambia, Namibia, Mozambique, Malawi and Uganda. The table below shows just how dramatic the non-correlation is.

The English Guardian is calling for an end to FGM, of course. But a far less dramatic non-correlation has been used to justify three randomized controlled trials of mass male circumcision in African countries. The results of these trials are have been used to justify a continuation of mass male circumcision, involving tens, even hundreds of millions of men, boys and infants and several billions of dollars. While HIV prevalence is lower among uncircumcised men than circumcised men in some countries, it is lower among uncircumcised men in others, while in several more countries circumcision status makes no difference. The correlation coefficient is roughly zero.

Results of further research into mass male circumcision is being presented to 16,000 attendees at the Melbourne HIV conference this week, research carried out on people who are not aware that they are guinea pigs for the current obsession with the operation. Because, as the figures show, we have no idea why circumcision sometimes appears to 'protect' against HIV and why it sometimes appears not to. Nor do we have any idea what proportion of HIV is transmitted through sexual contact and what proportion is transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

Similarly, we have no idea why HIV prevalence is so high in some African countries but so low in others. The fact that HIV prevalence is very low in countries that practice FGM is not seen as justification for carrying out trials of the operation on millions of people and presenting the results at an international HIV conference (such trials would probably be carried in secret). In fact, it is assumed that FGM status is seen as irrelevant to HIV transmission, and that, even if it is somehow relevant, carrying out trials into the operation as a HIV intervention would be entirely unethical.

International health and development institutions, the UN, the mainstream media, political and religious leaders all around the world, and many others, condemn FGM and would not consider it as a means of reducing HIV transmission. They would not even condone carrying out field trials into any kind of FGM, not even the less damaging kinds, not even the kind that leaves no permanent damage, because it is not ethically justifiable to carry out such an operation for no medical reason, on infants, children, or even unconsenting adults. Quite right, too.

But the research carried out by the people slapping each other on the back in Melbourne, presumably at some considerable cost, were financed by the likes of the Gates Foundation (which also funds the English Guardian's Development section, where the FGM article appears), FHI 360, Engender-Health and University of Illinois at Chicago. Several (if not all) of these institutions have their origins in a 'population control' theory of development, the belief that the population of developing countries is too high, and lowering birth rates will increase development and reduce poverty; less polite people would call this 'eugenics'.

I wonder if these parties have some information about, or beliefs about, mass male circumcision having some negative influence on fertility. Because, if they were to believe the same thing about FGM, would they also promote it with the same energy and persistence (and funding, and institutional backing)? What about other means of reducing fertility, such as Depo Provera, which has been associated with higher rates of HIV transmission? Gates and other 'population control' organizations certainly do promote that.

So promoting your favorite 'public health' intervention as a means of reducing HIV when the evidence is slim is bad enough. But this intervention involves something that is ethically unjustifiable unless it is carried out for medical reasons. So these various parties went a step further: they carried out, and continue to carry out, 'trials' of this operation on millions of people. The excuse is that it 'reduces HIV transmission'. But using that kind of evidence, so does FGM.

Genital mutilation without consent is not ethically justifiable; the fact that HIV prevalence is lower in countries where genital mutilation is common does not justify mass male circumcision programs, where millions of people are unwitting guinea pigs to this neo-eugenicist experiment. Those promoting mass male circumcision programs, funding them or working on them are involved in a crime of inestimable proportions, and must be stopped.


Wednesday, July 23, 2014

Millennium Development Goals For All, But At All Costs?

A survey was carried out in one district each in Kenya, Tanzania and Zambia to establish which factors are associated with health facility childbirth (thus shedding light on which factors are associated with the decision to give birth elsewhere, perhaps at home). Health seeking behavior is strongly associated with wealth, education, and urban residence; wealthier, better educated women living in urban areas, in general, are more likely to give birth in a health facility.

These factors are of especial interest because of their association with HIV. Wealthier, employed, better educated, urban dwelling women in African countries are often more, rather than less likely, to be infected with HIV. The tables below are for Kenya, Tanzania and Zambia, but these trends can also be found in other countries. The first table shows HIV prevalence by wealth quintile, with prevalence being lower among poorer people and higher among wealthier people.
Wealth quintile tableThe next table shows HIV prevalence in males and females, by employment and by urban/rural residence. Males are far less likely to be infected than females, unemployed people are less likely to be infected than employed people and rural dwelling people are less likely to be infected than urban dwelling people.
Employment residence
The third table shows that HIV prevalence is sometimes lower among those who have less education and higher among those with primary education in Kenya and Tanzania and those with secondary education and beyond in Zambia. (Note, figures for education are for attendance, not attainment, so they don't tell you that much. But MDG 2 is about 'achieving universal primary education', not about academic attainment.)
Receiving antenatal care at a health facility is part of the Millennium Development Goal (MDG) number 5, to improve maternal health. Therefore, it is not surprising that all 14 African countries I have looked at have a very high score for this goal, all ready for 2015. But the goal does not consider matters such as conditions in health facilities, skills of providers, facility practices, equipment, supplies, etc. So the percentage of women delivering in health facilities and the percentage of deliveries attended by a skilled health provider are far lower, being out of the MDG limelight.
ANC tableFor information on health facility conditions, equipment and supplies, there are Service Provision Assessments for each of the three countries, showing that there are many serious lapses. But questions about whether skilled providers are skilled, and of how skilled they are, are less often asked (particularly in relation to the MDGs). Another paper, entitled "Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward", addresses this issue.

Skill levels overall are not impressive and are low in some areas in the countries involved (Nicaragua, Benin, Ecuador, Jamaica and Rwanda). The researchers note that "knowledge of a procedure is no guarantee that it can be performed correctly", but also that problems are not solely due to a lack of skills or training, that some are due to lack of equipment, supplies and other things.

The first article estimates that skilled birth attendance could substantially reduce maternal deaths "presuming that facilities meet standards of quality care." Quite. But various sources of data show that health facilities often don't meet standards of quality care. The possibility that health facilities may be the source of a considerable proportion of HIV infections in high prevalence countries must be considered urgently if healthcare transmitted HIV, and other diseases, are to be averted.

Reducing maternal deaths is a laudable goal, but it is nothing short of unethical to encourage women to attend health facilities where the conditions are likely to be unsafe. Right now, failing to achieve MDG 5 may even be preferable to achieving it. Of course deaths from hemorrhage, obstructed labor, puerperal sepsis and pre-eclampsia must be reduced, but not at the cost of increasing incidence of HIV, hepatitis and other bloodborne diseases.


Wednesday, July 16, 2014

Kenya: Needle Exchange Programs Could Save Lives

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

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

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

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

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

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

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

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

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

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

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


Monday, July 14, 2014

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

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

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

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

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

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

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

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

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

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

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


Friday, July 11, 2014

UNAIDS and Uganda: Prejudice Begets Prejudice

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

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

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

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

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

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


Thursday, July 10, 2014

Denial Reigns Supreme in the HIV Industry

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Wednesday, July 9, 2014

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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


Thursday, July 3, 2014

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

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

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

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

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

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

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

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


Wednesday, July 2, 2014

Hepatitis B Virus and Kenya's Mass Male Circumcision Programs - Why the Secrecy?

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

With all the posturing in the recently released Kenya Aids Indicator Survey (2012) about mass male circumcision, whether performed in completely unsterile conditions found in traditional settings or the (hopefully) more sterile settings of health facilities, nothing was mentioned about hepatitis B or C. But an article in the East African describes a piece of research carried out by the Kenya Medical Research Institute into hepatitis B (HBV) which finds that prevalence is increasing.

Amazingly, the article admits that the "modes of transmission [for HBV] are similar to HIV — sexual transmission, contaminated blood products and mother to child transmission"; it is "passed from person to person through bodily fluids such as blood, semen or vaginal fluids". Following a recent paper on HIV transmission through medical injections, it is very important to stress that HIV, like HBV, can be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.
The article is equally frank about the lack of research into HBV in Kenya: "scientists say the reason for the rise in HBV in Kenya is still unknown since no scientific study has been done to explain the phenomenon". 

In contrast, the HIV industry is a lot less frank about non-sexual HIV transmission, even though the country's Infection Control Policy admits that "Epidemiological data on HAIs [Healthcare Associated Infection] in Kenya is currently lacking, but the risk for HAIs is high". Slowly, some of these glaring gaps in research are being filled in, though the HIV industry displays a confidence that seems entirely unjustified.

Importantly, HBV among blood donors in Kenya is rising. Are those donating their blood being exposed to contaminated medical instruments through the blood transfusion services? The Kenyan Blood Transfusion Service is not able to supply enough blood to keep up with current demand, so they would need to make sure that people who donate are not being put at risk of infection with HBV or other blood borne viruses. While no one would want to scare people away from health facilities or from blood donation, keeping risks a secret would surely be a lot worse, wouldn't it?

The article suggests that the counties finding high rates of HBV are in the Northern parts of Kenya (which often have the lowest HIV rates). It is suggested that "The likely causes of HBV in the region are cultural practices like tattooing, circumcising without using sterilised implements and because the regions are dry and people may not be able to get proper nutrition that ensures strong immunity." As usual, there is a reluctance to ask if health facilities might also be somewhat responsible; does that mean these facilities will not be investigated, and that conditions, if unsafe, will not be improved?

There are various hepatitis related campaigns, but are WHO and other international health institutions going to ensure that all the people involved in the country's mass male circumcision programs, will be protected from infection with HBV and hepatitis C virus (HCV) as well? WHO makes vague claims about huge proportions of HBV and HCV being transmitted as a result of unsafe healthcare. But what exactly are the figures for 'priority' mass male circumcision countries? Again, it's likely that healthcare safety is more of a risk in these 'priority' countries, some of the poorest countries, with amongst the lowest levels of healthcare spending in the world, than it is in Western countries; why are we only given one, generalized figure, when the viruses must be much more prevalent in some countries than others?

Egypt, as (just one) example of a country with a serious hepatitis problem, has seen the figure for years of life lost (YLL) through HBV increase by 3,930% in the 20 years from 1990 to 2010. Liver cancer has increased by 361% in the same period. Cirrhosis has increased by 40% to become the number three cause of YLL, accounting for 1,127,000 YLLs, or 7.1% of all YLLs. Whether the almost 100% prevalence of circumcision in the country contributes to these figures is another question, but it shows what can happen in a country where there is a very high level of access to healthcare, yet where healthcare safety is not adequately addressed. One of the main reasons HCV prevalence is higher in Egypt than anywhere else in the world is because of schistosomiasis vaccination programs, which were carried out using inadequately sterilized glass syringes.

Reusable syringes and needles are no longer commonly used, but the WHO data shows that there is still a problem with unsafe injection practices. So the last thing high HIV prevalence African countries need is a vastly increased risk of bloodborne virus transmission through unsafe healthcare, whether this involves reuse of injecting equipment or other items that are used to pierce the skin during healthcare procedures. Mass male circumcision programs will likely increase the incidence of unsafe healthcare practices, including injections, and the WHO's claimed benefits in terms of averted infections may not be enough to outweigh the risks involved.

Even if levels of protection against sexually transmitted HIV outweigh the risks, and this is highly debatable (and debated, outside of the HIV industry), what about the risks of infection with HBV, HCV or other bloodborne pathogens, including HIV, during the circumcision procedure itself? Some recent research has questioned the safety of Kenya's health facilities. There are clearly more risks than those pushing the circumcision programs would like to admit; so will those who succumb to HIV industry pressure be advised of those risks? I suspect they will not.