Could sexually transmitted infection (STI) programs that
started many decades before have been involved in the inadvertent transmission
of HIV as early as the 1970s in Kenya? Those targeted by STI programs were
women and men who attended STI clinics, or presented with STIs or STI symptoms.
A short paper by Peter Piot is often cited to show that HIV prevalence went
from 4% in 1981 to 61% in 1985 (Piot P, 1987) , and that therefore
sex workers (and their clients) must have been incredibly sexually active, and
also far more efficient at transmitting the virus to men through heterosexual
sex than one might expect (given what has been shown about transmission rates
since then). But the possibility that these sex workers and their clients were
infected through unsafe healthcare practices in STI and other clinics has never
been ruled out.
Jacques Pepin in The
Origins of AIDS argues that early STI programs were almost definitely
involved in spreading HIV (Pepin, 2011) in the Democratic
Republic of Congo. But he uses Piot's paper to argue that sexual behavior took
over from unsafe healthcare at some time; why this happened, or when, is not
very clear. However, the papers below suggest that the very people among whom
HIV prevalence was found to be high would also have been frequent clients in
STI clinics. Conditions in health facilities probably improved during the 80s
and 90s, which would have accounted for the rate of new HIV infections peaking
in the early 90s and subsequently declining. But given that healthcare is not
particularly safe in Kenya now, we don't know if HIV is still transmitted
through unsafe healthcare, albeit at a far lower rate.
Could invasive family planning methods such as intrauterine
devices (IUD), inserted in insanitary health facilities, have been involved in
the transmission of HIV, perhaps also as early on as the 1970s? Family planning
was most accessible and most availed of in urban areas, and the users were more
likely to be better educated, wealthier and formally employed (these are still true
of family planning users). Some of the earliest institutions to work with HIV
in African countries were those involved in family planning. They were already
well established in many countries and persuading people to have smaller
families, through any means possible, was what they knew best. That’s not to
say they were particularly successful, but they certainly received the lion’s
share of funding at one time, until the HIV industry became the top heavy, cash
rich bureaucracy that it is today, where any big NGO that toes the party line
will get ample funding. Perhaps some of the industry’s obsession with sexual
transmission, to the exclusion of most forms of non-sexually transmitted HIV,
relates to their origins, which can include puritanical religious beliefs,
Malthusianism and neo-eugenicism, to name but a few.
Kenya is said to have been “the first country in Africa south
of the Sahara to adopt family planning as a national policy” (Fendall & Gill, 1970) , with the earliest
family planning efforts starting in Mombasa in 1952. At first, it was decided
that Kenya’s population growth was not particularly worrying and the policy
started off fairly moderate. There were 25 clinics by 1965 in a country with a
population of about 11 million (as of 1969). But in the early and late 60s,
censuses showed that population growth was about 3%, far exceeding death rates.
An average of 7 children were born to women reaching 50 years of age and
average life expectancy was 40-45 years. Those engaged in family planning
resolved to reduce fertility by 50%, with intrauterine devices (IUD) being seen
as the best contraceptive method for achieving this. Family planning was to be
integrated into public health services and it would be free and voluntary (although
costs involved in attending the clinic were not covered, which may account for
the relative popularity of longer acting methods, which didn’t involve repeat
costs).
The number of clinics had reached 160 by 1970, with the
biggest being set up in urban areas, along with some of the more heavily
populated non-urban areas. Smaller units and mobile teams operated in less
accessible areas (although some of the higher populated areas are not urban,
such as in the Western and Nyanza provinces, where population is also dense). The
Family Planning Association of Kenya claimed to have 17,000 clients in 1965, of
which 70% were urban and 30% were rural. It is possible that independence
interrupted progress that had been made in the previous two decades. With a
growing population and limited revenue, the government needed to provide the
free health service they had promised. But the first 20 years or so of family
planning may have set some of the patterns that continued for the two or three
decades following, and perhaps still exist. Contraception tends to be far more
common in urban areas, among better educated, wealthier, urban dwelling people.
British colonial concern about sexually transmitted
infections (STI) dates back at least to the 1920s and by the 1970s resistance
to antibiotics and penicillin for the treatment of gonorrhea was already common
in rural and urban areas. This may suggest that people with STIs had been able
to access health services for some time, but that those services were not able
to eradicate the most common infections. It is likely that many people did not
return for some lengthier forms of treatment, which could involve a lot of
discomfort, as well as considerable expense from travel and other costs. A
paper from 1971 mentions ‘selected social groups’ being investigated in the
past for resistance, including people in capital cities, harbor areas, ‘special
elite groups’ (whoever they may be), foreign soldiers and ‘hostesses catering
for them’ (Verhagen,
1971) .
(These are some of the groups among whom HIV was later found to be highest.)
But the authors suggest that these groups are not representative of the
population as a whole and exclude the majority of gonorrhea patients. It is
hinted that the reason these groups are targeted in Kenya is that they may have
been the groups most likely to be infected in wealthier countries, such as the
UK, but that the analogy didn’t quite work. It is noted that Mombasa and
Nairobi have ‘special VD clinics’, although the one in Mombasa only treats sex
workers, whereas the one in Nairobi also treats the general population.
A paper published the following year aims to establish the
determinants of gonorrhea in Kenya (it is notable that, out of the few papers
available in full, many are about gonorrhea, fewer are about other STIs; also, most
studies tended to be carried out in a handful of countries, with Kenya being one
of the handful). It uses data from monthly checkups for sex workers at the
Mombasa and Nairobi clinics mentioned above (Verhagen & Gemert, 1972) . One of the authors,
Verhagen (and perhaps some of his contemporaries), is interesting for being a
lot less judgmental than one might expect, especially given the deep racism
later found in institutions working with HIV. Some questions about sexual
behavior were deemed ‘too intrusive’ to ask people in their control group. UNAIDS’
criteria for ‘sex work’ is often inclusive enough to be applicable to almost
every sexually active person in the country, and even many people who are not
sexually active. The authors also draw attention to the fact that attendance
for all medical services increased rapidly when treatment became free in 1965.
Gonorrhea tends to infect people who may be more ‘promiscuous’,
such as sex workers and their clients. Simple supply and demand would suggest
that sex workers must be fairly small in number, whereas clients need to be
plentiful. As sex workers are usually female and clients usually male,
gonorrhea may therefore be expected to infect more males than females. Verhagen
and Gemert find that the male:female ratio is 2:1 in 1964, rising to 6:1 in
1970 and 8:1 the following year. They note that the ratio for syphilis is
usually around 2:1. The authors are not able to estimate incidence of gonorrhea
but they conclude that Kenya has relatively low incidence, as the disease
globally is said to be currently the most common notifiable disease after
measles.
Despite earlier findings that patients with STIs are “found
among distinct social groups such as the lower social strata, members of
migratory or itinerant professions, and other groups characterized by social
instability”, this paper concludes that there is “a striking similarity between
patients and controls.” Many of the women were single and unemployed (although
many were sex workers) and many people who were married and had STIs spent long
periods away from their partner, this being more a feature of urban, rather
than rural living. Men with STIs usually attributed their infection to someone
other than their wife, while women with STIs were often less well educated, as
well as being single and not conventionally employed, which strongly suggests
that they were very poor. Even among those deemed to be sex workers, it was ‘the
smarter and more expensive girls’ who received the monthly checkup, so they may
have been less likely to be infected with gonorrhea and other STIs than other
clinic patients.
UNAIDS and the HIV industry have a fondness for identifying
(and thereby stigmatizing) multitudes of HIV ‘risk groups’, at least one of
which almost everyone falls into at some time. In contrast, Verhagen and Gemert
assume “that encounters in bars, brothels, dance-halls, and in the street
(termed the BBDS category) were the more casual and usually reflected prostitution
and promiscuity”. This must have made it a lot easier to target people at risk
of being infected with an STI, or of transmitting it to others. The difference
in approach may explain the lack of successful HIV prevention interventions,
especially before the widespread availability of antiretroviral drugs. Half of
the male patients are said to have been infected by someone they met in a
brothel, a bar or a dance hall, with brothels only accounting for 10% of all
gonococcal infections; the other half met the sexual partner on the street or
near where the partner lived. Although the fairly small number of ‘promiscuous’
females infect a larger number of males, fewer of those males go on to infect
another partner, such as their wife. The authors neither conclude that all (or
most) men are promiscuous, nor that all (or most) females are. The phenomenon
of large numbers of single men and married men who live away from their partner,
which was very often the case in cities, and a small group of women to cater
for their sexual needs, is identified as a major driver of high rates of STI
transmission (as it was later said to be in relation to HIV). Even the ‘breakdown
in traditional ethics’ said to result from migration and urbanization, frequently
remarked on later, had been noted by authors several decades before.
Generally, far fewer women than men were infected with
gonorrhea and other STIs. Quite a number of these women were said to be ‘non-promiscuous’,
having been infected by a promiscuous partner. Sex workers are often badly educated,
unemployed migrants whose marriage may have broken down and who come from a
particular tribe associated with these and other factors. Comparing their study
participants with a control group, it is found that many of the males are
young, badly educated, unemployed, living in overcrowded conditions and are
recent arrivals in the study area. The authors warn that “The self-image of an
indiscriminately promiscuous community (which in view of our findings in regard
to the regularly married is wrong), ostracism against prostitutes and emotional
outbursts blaming a particular sex or group of persons are of no help.” That
warning, along with others, was to fall on deaf ears. “No distinct high risk
groups were found” in the course of this study.
The above papers are of interest to a history of HIV in
Kenya because many sexually transmitted infections are a lot less likely to be
transmitted through any other route, such as unsafe healthcare. In contrast,
HIV is relatively difficult to transmit sexually and easy to transmit through
unsafe healthcare, unsafe cosmetic practices and various skin piercing
traditional practices. As I have mentioned in earlier posts, HIV is often
correlated with higher wealth, better education, employment (as opposed to
unemployment) and urban residence, and prevalence is generally higher among
women. Many of the factors involved in the transmission of HIV seem to the opposite of those involved in
transmission of gonorrhea and some other STIs.
What about factors for STIs and factors for HIV that seem to
overlap, such as involvement with sex work, migration, mobility and the like?
The above papers, along with others from the decades preceding the discovery of
HIV, suggest that sex workers, immigrants, transport workers, migrant workers
and those engaged in certain occupations had long been targeted by STI
programs. These programs were most prominent in areas that attracted migrants,
cities and areas with high labor needs. Could some of these programs have been
inadvertently involved in the transmission of HIV to the groups that were later
found to have been infected, as if en
masse? What about family planning? Could the use of IUDs have infected many
women? There is certainly plenty of evidence that conditions in health facilities
were poor, that health facilities were oversubscribed, underfunded,
understaffed and not the safest place to go for preventative or curative
treatment. Even the connections between population growth and density alluded
to by some HIV commentators may relate to the relative success of family
planning and STI eradication programs in urban, as opposed to rural areas. Higher
levels of education and wealth are generally associated with both family
planning and health seeking behavior in general; but while these factors are
associated with higher HIV prevalence, the opposite is true of STIs.
The massive increase in HIV prevalence among sex workers
found in Nairobi, from 4% to 61% between 1981 and 1985, may have been a result
of unsafe healthcare, especially in facilities providing STI and family
planning services. Historical and contemporary studies show that HIV is only
sometimes transmitted sexually; patterns of infection only overlap to a limited
extent with those for STIs. The relative contribution of sexual and non-sexual
transmission to Kenya's epidemic remains unknown; until it is known, epidemics
like that in Kenya will continue indefinitely. Yet the HIV industry is still happy
to accuse those infected of being highly promiscuous, and of being indifferent
about transmitting the virus to their partners and infants.
[The list of publications below is short and I will comment
on other publications in the next part.]
REFERENCES:
Fendall, N., & Gill, J. (1970). Establishing
Family Planning Services in Kenya. Public Health Reports, 131-139.
Pepin, J. (2011). The Origins of AIDS.
Cambridge : Cambridge University Press.
Piot P, P. F.-A. (1987). Retrospective
seroepidemiology of AIDS virus infection in Nairobi populations. J Infect
Dis, 1108-12.
Verhagen, A. (1971). Diminished Antibiotic Sensitivity
of Neisseria gonorrhoeae in Urban and Rural Areas in Kenya. Bulletin of the
World Health Organization, 707-717.
Verhagen, A., & Gemert, W. (1972). Social and
epidemiological determinants of gonorrhoea in an East African country. British
Journal of Venereal Diseases, 277-286.
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