Hepatitis, TB, HIV and Ebola: Healthcare Associated Epidemics?

It is sometimes claimed (by UNAIDS and others) that if HIV was frequently transmitted through unsafe healthcare in sub-Saharan countries, then hepatitis C (HCV) would also be common in the same countries, because HCV is usually transmitted through unsafe healthcare (dental procedures, surgery, stitches, etc). Indeed, HIV prevalence is often higher in countries that have low prevalence of HCV; and the high HCV countries tend to have low HIV prevalence.

However, given that it is well established that both viruses can be transmitted through unsafe healthcare, and that unsafe healthcare practices are probably very common in most (all?) African countries, the non-correlation between HIV and HCV prevalence seems like a very weak and unappealing argument. Because we don't know the relative contribution of HIV transmission through unsafe healthcare, neither do we know how much transmission is a result of heterosexual risk.

Blaming high rates of HIV transmission almost exclusively on 'unsafe' heterosexual behavior has a number of dangerous consequences. For a start, it stigmatizes those who are already infected. It also results in people who don't engage in 'unsafe' sexual practices failing to recognize their risk of being infected. More serious still, it means that public health programs aiming to influence sexual behavior will be relatively ineffective.

HCV prevalence in Egypt is the highest in the world and HIV prevalence is low. But a recent survey concludes that "Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt". It sounds like measures to reduce transmission have not yet been completely successful. More worryingly, another paper finds that "there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities".

What about countries where HIV prevalence is extremely high, such as South Africa? HCV prevalence is very low, so the UNAIDS argument above would suggest that unsafe healthcare does not play a significant role in HIV transmission. But does that mean unsafe healthcare is unimportant? After all, resistant strains of TB have been transmitted in hospitals in South Africa and this has even spread beyond South Africa, to surrounding countries, and even to another continent.

In reality, we don't know that much about HCV in the Africa region. A review of research on the subject concludes that "Africa has the highest WHO estimated regional HCV prevalence (5.3%)" in the world. That's a striking figure, because HIV prevalence across the whole sub-Saharan African region is also around 5%. There are two serious viral pandemics on the continent that may both be driven to a large extent by unsafe healthcare.

HCV concentrates in certain countries and in parts of certain countries. But so does HIV. Prevalence is relatively low in most of Kenya, for example, only a few percent. It's high in the two large cities, Nairobi and Mombasa, and highest in three (out of 47) counties around Lake Victoria. The situation in Tanzania is similar, with three high prevalence areas. In Burundi and Rwanda prevalence is also low, except in the capital cities.

So the fact that most high HIV prevalence areas do not overlap much with high HCV prevalence rates is not a very convincing argument that the two viruses are transmitted in completely different ways, the former being mainly transmitted through heterosexual sex and the latter through unsafe healthcare. Comparing HCV and HIV patterns only makes the heterosexual sexually transmitted HIV contention look all the more infantile.

The good news, then, is that improving healthcare safety would reduce transmission of both HCV and HIV, and even a range of other diseases that don't get anywhere near as much attention as HIV. Good healthcare is also safe healthcare, whereas indifferent healthcare, with low standards of infection control, results in alarmingly high rates of transmission of serious diseases.

Journalists have recently had their attention drawn to the potential drawbacks of neglecting healthcare; ebola is difficult to control in a healthcare environment (as opposed to a rural village, where it appears to die out quite quickly). But it has been shown that it is difficult to control in healthcare facilities because of unsafe practices, such as reuse of skin-piercing instruments, gloves and other disposable supplies, lack of infection control procedures, a shortage of skilled personnel, etc.

One newspaper article even made a connection between ebola and HIV, suggesting that because many West African countries had relatively low HIV epidemics, investment in healthcare was lower, hence the weakness of the response to ebola.

Their analysis is not very perceptive. HIV-related investment in Sierra Leone and Liberia has been high enough to ensure that more than 80% of HIV positive people are provided with antiretroviral treatment. Guinea is way behind them in this respect, with less than 50% of people receiving treatment. But spending money on preventing supposedly sexually transmitted HIV, and on treatment, does nothing to address unsafe healthcare.

HCV, HIV, ebola, TB and various other diseases can be transmitted through unsafe healthcare, so this is an argument for strengthening all health facilities in all developing countries. A human right to health does not make any sense if healthcare is so unsafe that patients risk being infected with a deadly disease when they visit a health facility. So 'strengthening' healthcare must include making health facilities safer.

It is hardly surprising that people in Guinea, Sierra Leone and Liberia run from health authorities and hide family members who are sick. The prospect of having your house searched by people in hazmat suits, sometimes backed up by people with guns, is frightening enough. But if your property is dragged outside in broad daylight and burned in public, and your sick relatives are hauled off to a ramshackle, understaffed, undersupplied health facility, these must extremely traumatic experiences.

If health facilities are unsafe, healthcare associated transmission of serious diseases will only increase as more people are admitted to them. Transmission rates will not go down until safety is made a priority; this applies as much to HIV as it does to HCV, ebola, TB and other diseases. The additional assurance that people will not be exposed to life-threatening diseases through unsafe healthcare should also increase demand for healthcare.