Misplaced Condemnation in Cambodian Nosocomial HIV Outbreak

The ongoing inquiry into an outbreak of HIV in several Cambodian villages has so far found more than 160 cases. Most cases were found in one village, but 20 were found in a nearby village and a few more in a third.

However, the inquiry needs to be expanded to include all villages where such an outbreak may have occurred. It also needs to be expanded beyond unlicensed premises and practitioners. It should include all health facilities, pharmacies, practices and anywhere skin piercing procedures take place.

The reason the inquiry needs to be so broad is that anyone in the country may be as ignorant as their esteemed leader, Hun Sen, about the risk of being infected with HIV through unsafe healthcare. Many people may only have heard about sexual risk; those who have heard about non-sexual risks have probably heard that it is very unlikely, which is the received view propagated by UNAIDS, WHO, CDC and the like.

Also, the CDC estimates for the risk of being infected through reused injecting equipment seem unbelievably low. They claim that the risk from needle-sharing during injection drug use is 63 in 10,000. The one unlicensed practitioner arrested so far has admitted to reusing syringes and needles, so the risk may be similar to that faced by injection drug users. But compare those CDC figures to estimates on the Don't Get Stuck With HIV site.

If the risk is as low as CDC's 63 in 10,000 then this single unlicensed practitioner must have an impossibly large number of clients, who receive a lot of treatment that involves skin piercing of some kind. It is far more likely that other practitioners, licensed and unlicensed, also take risks. Yet, infections will only be brought to light if the investigation is broad and thorough enough.

The investigation also needs to report honestly. Hun Sen may wish to protect his country's image of one that has avoided a very serious HIV epidemic; UNAIDS may wish to continue denying non-sexual transmission through unsafe healthcare; CDC may not want to review their estimated risk, for whatever reasons, etc.

But the most important thing is to discover how people have been infected, then cut off these routes to infection. This kind of outbreak could happen again and again, because neither practitioners nor members of the public are being warned of the risks of infection through reused medical instruments and other unsafe practices.

The investigation so far has demonstrated one of the dangers of the sort of culture of blame that has been developed by UNAIDS and the HIV industry. If those found to be engaged in unsafe practices are persecuted, threatened, imprisoned or otherwise punished, the investigation is unlikely to bring too many outbreaks and unsafe practices to light.

Those already infected need to be identified, and given treatment and support. Those at risk, likely to be a very large number of people, need to be proteted from harm.

The arrest of a single practitioner to date looks like a case of scapegoating, somewhat resembling Libya's reaction when an outbreak was discovered there, or the Ugandan nurse sentenced to several years in prison for 'negligence' because she is said to have risked infecting an infant with HIV (she was released after serving nearly one year but the conviction was upheld).

Condemnation of those engaging in unsafe practices, when the HIV industry itself has failed to warn practitioners and patients about the risks, is entirely misplaced. It only adds to a systematic failure to protect people from being infected, as well as exposing health practitioners and others to abuse and accusations of 'deliberate' transmission of HIV.

Cambodia's Hun Sen in the Dark about HIV/AIDS

Prime Minister Hun Sen of Cambodia is probably not the only national leader totally confused about HIV/AIDS. The news that over 100 people may have been infected with HIV as a result of an "unlicensed" doctor reusing skin piercing equipment, such as syringes, needles, intravenous drips and possibly others, underlined the leader's complete ignorance about HIV transmission.

The prime ministers first response was to doubt if the HIV tests were accurate. But he seems to believe that HIV is exclusively transmitted through sex (and perhaps from mother to child or through injecting drug use). He doesn't seem aware of transmission through blood exposure as a result of unsafe health, cosmetic or traditional practices. He also seems to believe that the quack arrested for performing these unsafe procedures must himself have been infected with HIV, which is not the case.

If one of the quack's patients was HIV positive, reusing equipment that pierces the skin, or even is inserted into the mouth or other orifices, runs the risk of transmitting HIV and various other pathogens.

It wasn't that long ago that Cambodia was predicted to be the first country to eliminate HIV transmission altogether, perhaps in the next few years. The epidemic is very small there and most transmission is likely to be through male to male sex and intravenous drug use.

But the outbreak in Roka Commune, Battambang Province shows that there are other risks. This kind of outbreak is likely to have happened many times in many countries over the past few decades. What makes this outbreak different is that it was noticed and (hopefully) investigated. Many quacks, perhaps even legitimate healthcare practitioners, may be reusing equipment, completely unaware that this could be exposing their patients to HIV, hepatitis and other bloodborne diseases.

A survey in Kenya and several other African countries found that people who have had injections in the past 12 months are far more likely to be HIV positive than those who have not. Babies in Mozambique and Swaziland have been found to be infected with HIV even though their mothers are negative (or the mothers have been infected by their babies). Women who only have sex with other women, which is extremely low risk, have been infected.

But in African countries this kind of outbreak remains uninvestigated. The women in Mozambique have never been told how their babies may have been infected, and have been allowed to believe that it was their (the mother's) fault. The women who have sex only with other women have been told that such sexual behavior must be, after all, risky. And the many people who have probably been infected through unsafe healthcare have never been given any explanation.

So it's not surprising that PM Hun Sen doesn't believe the results: he, like most people in most countries, rarely hear anything about non-sexual transmission of HIV, through unsafe healthcare, cosmetic and traditional practices. This is in a country where healthcare conditions are poor and a lot of people resort to self medication, quacks or other people with few or no healthcare skills.

Hun Sen asks if an 80 year old person or a child are likely to be infected with HIV; and the answer is yes, anyone can be infected through any skin piercing practice where the equipment is reused and conditions are unsterile. They are also likely to be infected with hepatitis and any other bloodborne pathogen that is going around. Hospitals, dental surgeries, tattoo parlors, hairdressers and many other settings may be similarly risky.

So it's time for UNAIDS and the WHO to come clean, because if national leaders are so confused about HIV modes of transmission, how clear can members of the public be? If we are constantly bombarded with misleading statements about sexual risks, but rarely told about serious non-sexual risks, everyone could be as confused as the Cambodian Prime Minister.

Religion, Former Colonial Powers; Fighting Prejudice with Prejudice?

In a paper entitled 'Religious and Cultural Traits in HIV/AIDS Epidemics in Sub-Saharan Africa', the authors conclude that the Islamic faith is protective against HIV. Their conclusions about the role of colonial powers is not quite so clear, except to the extent that former British colonies (FBC) tend to be predominantly Protestant (or non-Catholic) and most of the countries that are predominantly Catholic are former non-British colonies (FNBC).

Making associations between HIV and religion, high prevalence and Christianity, low prevalence and Islam, high prevalence and FBCs, lower prevalence and FNBCs, etc, are very tempting. All the predominantly Muslim countries in Africa have low HIV prevalence, with Guinea-Bissau (3.9%) being the only one with a figure higher than 2% (and it is only 45% Muslim). Prevalence in countries with 90% or more Muslims only reaches a high of 1.1% in Sudan.

All the countries with prevalence above 4% are predominantly Christian; out of these, only four are FNBCs. There are nine countries with over 1 million people living with HIV. Only one is an FNBC (Mozambique) and only one is roughly evenly split into Christians and Muslims (Nigeria). All the highest prevalence figures are in the Christian dominated Southern region, and the four with prevalence below .4% are in the predominantly Muslim North.

But things come apart a bit when you look at countries that are Christian, but not predominantly Protestant. There are six predominantly Catholic countries, all FNBCs, where the highest prevalence figure is 2.9%; all these countries are in Central Africa. Yet, a number of countries made up of between 20% and almost 50% Catholic populations have some of the highest prevalence figures, too.

While Muslims and Catholics (ostensibly) oppose extra-marital sex, homosexuality and various other phenomena, so do Protestants and other non-Catholic Christian churches. Suggesting that such opposition is stronger or more active in countries with lower HIV prevalence risks arguing in a circle.

Some useful generalizations can be made, such as very high prevalence in Southern Africa, very low prevalence in North Africa, mainly low prevalence in West and Central Africa and high prevalence in East Africa. It is also broadly true that most predominantly Christian FBCs are Protestant dominated, rather than Catholic dominated. With the exception of Mozambique, prevalence in all FNBCs is never higher than 5%; but these countries can be predominantly Muslim, Christian, mixed, or Catholic.

There are two major objections to the analysis given or implied in this paper. The first is is that patterns and generalizations that can be made at the regional level, or even at the country level, do not always hold within countries; the second objection is to the assumption that HIV is almost always sexually transmitted.

The authors find some broad correlations but they do not discuss causality. They claim that the populations of countries such as Egypt, Tunisia and Algeria, for example, were protected from HIV because of their Muslim faith and the practices that go with that. But those countries, and others in the North, might have been 'protected' by one of the largest desert areas in the world, the Sahara.

In addition, HIV in those countries is mainly subtype B, which is generally associated with male to male sex (and to a lesser extent injected drug use). Subtype B is rare in other parts of Africa, with the exception of South Africa (where it mainly seems to infect men who have sex with men). HIV epidemics appear to form different patterns across regions and countries. But it also forms different patterns within countries.

High HIV prevalence in the Southern region may be facilitated, to some extent at least, by the well developed infrastructure there, infrastructure that would have been built by the British Colonial power. The same colonial power built far fewer roads or other infrastructure in East Africa, and none at all in Central Africa, where they had very little control.

However, they had control of a number of West African countries, where there is generally a strong infrastructure. Why did HIV not spread around West Africa to the extent it did in Southern Africa? Well developed infrastructure may partly explain variation in HIV prevalence between some countries and some regions, but it doesn't explain enough. There are clearly factors operating within each country that account for some variation in HIV prevalence.

Regarding the second objection, the authors link the Muslim faith with certain moral precepts which they feel protect people from HIV. However, the majority of people in non-Muslim countries were not infected because they engaged in 'immoral' behavior. Even 'official' figures show that the bulk of people infected in many high prevalence countries have only one sexual partner, and most of those partners are HIV negative.

The 'promiscuous African' stereotype can not be used to explain HIV transmission because it is a prejudice, not an empirical fact about people with HIV, or about people from countries with high HIV prevalence. But similarly, the 'non-promiscuous Muslim' is also a stereotype, however positive. If you can not discern a person's sexual behavior from their HIV status, nor discern a person's HIV status from their sexual behavior, the conclusion that being a Muslim is protective against HIV is unwarranted.

Religion and former colonial power may be two important influences in HIV epidemics, but the authors fail to show convincingly how they operate on HIV transmission. Arguing that those and all other relevant factors relate exclusively to indivicual sexual behavior fails to explain the spread of HIV within countries. Heterogeneity between and within African countries suggests that HIV prevalence is not all about sex, and that not all factors operate at the individual level.