Hepatitis C Virus: Revenge of the Killer Icebergs

The comments following an article about hepatitis C (HCV) appearing in the English Guardian suggest that some people still associate the virus with illicit drug taking, illicit sexual practices and those who engage in such activities. Sadly, the article doesn't make much effort to dispel such views.

Several of the people commenting who have been infected with HCV sound as if they don't quite understand how this came about, although they know that they have never engaged in any of the well publicized activities that are said to constitute the most serious and the most common risks.

We shouldn't be facing this problem with HCV; it's much too like the problem we still face with HIV, the view that it mainly infects people who engage in illicit activities of some kind, their partners and even, sometimes, their children. Trying to scare people about heterosexual HIV being the tip of an iceberg, when public health authorities knew perfectly that that wasn't true, backfired.

It will backfire with HCV too. Many people are still afraid to be tested for HIV, to be frank about their status, to discuss it with people with whom they may become sexually involved, etc. So why are we risking the same sort of stigmatization with HCV?

The article says: "Only in recent years have doctors realised that the hepatitis C virus (HCV) can be sexually transmitted. As it is carried in the blood but not present in significant amounts in semen and other bodily fluids, the risk of transmission during sex was presumed to be negligible. That was until patients who had never injected drugs started testing positive."

But patients who had never injected drugs, nor had any other identifiable risks, may have had an endoscopy, colonic irrigation, treatment with contaminated vials (generally multi-dose vials), been exposed to insulin pens, fingerprick lances, been circumcised in a non-sterile setting, received certain beauty treatments (eg, blackhead removal), complementary therapies, or skin-piercing and other invasive traditional practices, shared certain types of haircutting equipment, including machinery, donated blood (donors can face a risk from reused equipment), served time in prison, had anything inserted into a mucus membrane (including hands wearing reused surgical gloves), etc.

The article mentions sharing toothbrushes and razors as if that's the end of it. The research that the article refers to makes it clear that the relative contributions of various risk factors, whether sexual or non-sexual, have not yet been established.

Mentioning that "Rougher sex, anal sex and the sharing of sex toys, especially among people who are also infected with HIV, make sexual transmission possible" may spice up the article a bit, but it could also deflect attention from other risks. These other risks may well be a lot less likely to transmit HCV (or HIV) than certain sexual practices or intravenous drug use, but the list includes things that many people do many times a year.

We need accurate and comprehensive information about hepatitis C, not scare tactics resembling the ones that failed so devastatingly with HIV. In addition to common skin-piercing and invasive healthcare, cosmetic and traditional practices, it is possible that ordinary, everyday sex, transmits HIV; it may not be as risky as the spicy kinds journalists like to report on, but it is likely to be a damn sight more common.

Syringe Reuse - HIV Industry to Revise Finger Pointing Strategy in Africa?

The news that the World Health Organization (WHO) is calling for exclusive use of auto-disable syringes, which are designed to break if reused, is probably the most significant advance in the reduction of HIV transmission in developing countries to be announced in many years. It should also reduce transmission of other blood-borne viruses, such as hepatitis B and C, also ebola and MERS.

The WHO has started their global campaign to increase awareness of the dangers of unsafe healthcare, especially through reused syringes, needles and other skin piercing equipment, and have issued a brochure on injection safety.

It's lucky that the inventor of the K1 auto-disable syringe, Marc Koska, heard about the problem of reused injecting equipment in 1984. Only a few years later attention was drawn away from unsafe healthcare to unsafe sexual behavior as the main route of transmission for HIV.

Although HIV in wealthy countries now mainly infects men who have sex with men and people who inject illicit drugs, and this was already clear in the late 1980s, public health institutions decided to emphasize the risks people face from heterosexual sex.

Perhaps these institutions had their reasons, and the campaign was 'successful'; many people all around the world still believe that heterosexual sex is the biggest risk for HIV. The risk to heterosexuals was, and is, very low, but few people around in the 1980s could forget the relentless scare campaigns.

But in poorer countries, most people becoming infected with HIV were clearly not men who had sex with men or injecting drug users. They were just ordinary people, many of whom who had never had sex, never had 'unsafe' sex, or only had sex with a person who was also HIV negative.

There were also a lot of infants infected by their mothers, and there still are, although the prevention of mother to child programs have been among the most successful in the history of HIV.

The issue of non-sexual transmission of HIV in developing countries remained ignored, even strenuously opposed by what became an enormous HIV industry. And so, those infected with the virus, and whose infants were infected with the virus, were accused of being promiscuous, careless, dishonest and even cruel to their family and those around them.

Perhaps this will herald in a new era, making it possible to raise the issue of non-sexual transmission of HIV through unsafe healthcare without accusations of denialism (although it seems to be the opposite of denial), being anti-scientific (although there is no shortage of evidence) or of diverting attention from the importance of sexual behavior, which was never as important as the massive scare campaigns would have us believe.

One newspaper article cites Koska as saying “I always wanted to be a superhero and save the world”. I don't know if he really said that, but I'd like to believe he did. Because the benevolence of his motives contrast strongly with the apparent motives of certain parties in the burgeoning HIV industry, for whom HIV transmission is but a route to wealth, power and career advancement.

Cambodia, Unsafe Healthcare, Injections: Time for a Changing of the Guard?

There's a very succinct set of photographs by Marc Koska of the SafePoint Trust about the HIV outbreak in Cambodia's Roka Commune. Over 270 people are said to have tested positive so far, several of whom have already died. Unsafe healthcare is thought to have been behind this outbreak, reuse of syringes and other skin piercing equipment by medical practitioners who do not have the knowledge, skills or equipment to avoid such occurrences.

Koska invented an auto-disable syringe many years ago, a syringe that breaks if you try to reuse it, but he has been lobbying health and HIV institutions to promote the use of this simple and cheap technology ever since.

It is highly unusual for the BBC to express the slightest hint of disagreement with the mainstream view of UNAIDS and other institutions, that HIV is almost always transmitted through unsafe sex, and hardly ever through unsafe healthcare. Perhaps because this outbreak was in Cambodia, where HIV prevalence is low, this story flew under the radar.

Sadly, as the article points out, use of auto-disable syringes is too late for those already infected, but it is not too late for other Cambodians, nor for HIV negative people living in countries where HIV and other blood-borne viruses are common and, more importantly, where safe healthcare is uncommon.

UNAIDS and others in the HIV industry have been ranting on about 'unsafe sex' and completely avoiding the issue of unsafe healthcare, even denying its possible role in the most serious HIV epidemics in the world, which are all in Africa. Perhaps this will bring various kinds of unsafe healthcare into focus, however belatedly.

Cambodia is not the only Asian country where unlicensed practitioners operate; and even licensed practitioners may reuse needles, syringes and other skin-piercing equipment. The practitioner who has so far been the only scapegoat is unlikely to be the only person to practice healthcare unsafely. The investigation should be global, not confined to a population of a few thousand.

As for African countries, it should be clearer than ever that unsafe healthcare must no longer be denied by UNAIDS and other health agencies as an important mode of transmission of HIV and other viruses in African countries. People shouldn't have to be Buddhist monks, very young or very old to be believed when they say they have not engaged in 'unsafe' sex, or any sex at all.

The UNAIDS view that HIV is almost always transmitted through 'unsafe' sex and hardly ever through unsafe healthcare is vehemently expressed in a BBC article from 2003, and these views don't appear to have changed since (although the UNAIDS official in question, along with some of her senior colleagues have since availed themselves of the revolving door).

The maliciously racist view of Africans that the senior UNAIDS official is, apparently, allowed to make public, doesn't seem to have changed either.

It's also worth bearing in mind that UNAIDS are well aware of the risks of healthcare transmitted HIV and other infections in developing countries. They publish a brochure warning UN employees not to use health facilities in such countries; this contrasts very strongly with what the BBC published the year before. Perhaps now they UNAIDS will promote this in Cambodia, and hopefully in Africa too?

Circumcision: Digital Manipulation May Lead to Reduced Vision

Following my previous post, I’ve put together some of the data available on HIV and circumcision on this site, along with some additional data, in order to emphasize a few points.

Convincing arguments have been made to show that there is no overall benefit found when comparing HIV prevalence among circumcised and intact men in a number of countries for which figures are available; prevalence is higher among circumcised people in some instances and higher among intact people in others.

This raises the question of whether circumcision, or perhaps circumcision on its own, might be irrelevant to heterogeneity among HIV epidemics. After all, there are other differences, aside from circumcision status, between the populations of various countries for which figures are available.

Here’s an example: there's a group of seven countries which were formerly colonized by Belgians, French and Portuguese (or remained uncolonized) for which circumcision/HIV related information is available. With the exception of Mozambique, the former Portuguese colony, HIV prevalence in the others is low to medium. The total number of HIV positive people in these countries is estimated at just under four million.

[Table available on Don't Get Stuck With HIV site]

But there's another group of nine countries which were formerly colonized by the British. Although prevalence is low in one of them, located in lower prevalence West Africa, the others are all high to very high prevalence countries, coming to a total of just over nine million HIV positive people. Indeed, about 80% of all HIV positive Africans reside in former British colonies, which comprise more than half the population of Africa.

[Table available on Don't Get Stuck With HIV site]

Undeniably, HIV prevalence and circumcision do show a very strong North/South divide. Most men (and many women) in northern African countries practice some form of genital alteration, known as circumcision when applied to men, and HIV prevalence is very low in these countries. In contrast, circumcision is not predominant in most of the highest prevalence countries in southern Africa.

There are fewer than 150,000 HIV positive people in Egypt, Libya, Algeria, Niger, Mauritania, Tunisia, and Morocco combined, these countries comprising almost 20% of the population of Africa. But I would argue that the northern countries did not 'successfully fight off' HIV, as is sometimes suggested. In fact, the virus didn't arrive in the region until the mid-80s, more than three decades after it established itself in eastern Africa.

There are sex workers, men who have sex with men, intravenous drug users, clients and partners of these groups in northern African countries, just as there are in all other countries in Africa (and the rest of the world). The enormous Sahara Desert may have shielded northern African countries to some extent from the spreading virus, but prevalence is not low there because ‘unsafe’ sex is less common than in southern countries.

Southern and eastern African countries are almost all former British colonies, whereas only a handful of former British colonies can be found in Equatorial, western or northern Africa. Of course, the British colonials didn't spread a virus they still hadn't heard of, nor did the non-British colonials avoid spreading it.

Rather, the colonials developed the structures that allowed the virus to spread, with varying levels of efficiency; the roads, railways and ports, the overcrowded cities, the oversubscribed health facilities, the industrial outlets, especially extractive industries, the huge pools of labor, living in squalor away from their families, etc.

So, the influence of certain types of administration on determinants of health (and disease) may be behind much of the heterogeneity found HIV epidemics in African countries. But there is nothing to lead one to the conclusion that circumcision status, or even sexual behaviour, are clearly linked to HIV prevalence.

If you start out believing that HIV is almost entirely transmitted through 'unsafe' sexual behavior, and that circumcision gives some level of 'protection' against HIV transmission, some of the figures bandied about might persuade you that it's a good idea to spend billions aggressively recruiting as many men as possible to be circumcised; but that's all down to your preconceived views.

CDC on Circumcision: Just Lie, No One Will Notice!

Professor Robert van Howe was requested, in his capacity as a pediatrician with an expertise in male circumcision, to peer-review the US Centers for Disease Control and Prevention's (CDC) draft recommendations following their 'Consultation on Public Health Issues Regarding Male Circumcision in the United States for the Prevention of HIV Infection and Other Health Consequences'. The full peer-review is available on the Academia.edu site, with some comments and a brief extract on the Circumcision Information website.

One might think, from the constant bombardment of articles in praise of circumcision, that there was a fair body of thought in favor, and a comparable body of thought against the practice. However, the majority of countries in the world do not practice routine male circumcision for 'medical' purposes, and only a minority do so for religious and/or cultural reasons. Enthusiasm for the operation for 'medical' reasons emanates almost entirely from the US.

Van Howe's critique is not technically difficult, and many of the arguments against male circumcision would be widely accepted, perhaps even by those who have little familiarity with the subject. But the list of criticizms of the CDC's draft runs to over 100 pages, with the bibliography of literature supporting the case against the operation running into another 100 pages.

The CDC draft is found to lack scientific and scholarly rigor, neglecting important and relevant findings, but using reviews and other lower quality material instead. Research was carried out carelessly and reported badly. Grasp of basic epidemiology among those who wrote the draft is also low. Van Howe suggests that these apparent flaws may have been part of a deliberate attempt to bias the subsequent recommendations.

In addition to highly selective analysis of medical evidence, ignoring any that might not support what seem like CDC's prior belief in the virtues of male circumcision, the authors continue a long tradition among proponents of the operation of failing to discuss any kind of causal mechanism by which it might 'prevent' HIV or various sexually transmitted infections (STI).

While US professional medical associations resolutely stand by their long held regard for circumcision, equivalent associations elsewhere continue to express their opposition to it. The CDC's draft neglects to mention any of this substantial opposition by experts. Yet the intention of the CDC's recommendations are that they will form the basis of advice and information to be given by medical professionals to members of the public about the operation.

Van Howe's recommendation is that this draft be scrapped and the process be started again, from scratch. He also advises that they " review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa."

But what's this about Africa? Van Howe finds that much of the 'evidence' for the claimed benefits of circumcision in 'reducing' transmission of HIV and other STIs comes from studies carried out in African countries, despite being used to support their arguments that it should be routine in the US. These often-cited studies carried out in Africa are themselves highly questionable, were carried out by people who were already convinced that circumcision 'reduced' HIV transmission, and have spent many years (and many millions of research dollars) trying to push their agenda in African countries (with varying levels of success).

The US is by no means the lowest HIV prevalence country in the world. In fact, it has the highest prevalence among wealthy countries, despite spending a lot more per head on health than some others. The largest HIV positive population in the western world can be found in the US, even though there are probably more men there who were circumcised for 'medical' reasons than in any other country.

Van Howe's article may come closer to listing every major argument against male circumcision as a 'medical' intervention against HIV and STIs than any other; it certainly provides counter-arguments against the sort that the CDC draft seems to be filled, flimsy, half baked maunderings and puerile innuendo, apparently the best that many years of study by a whole team of researchers can muster. Even if you can't read the entire peer-review it will be a good source of information, with a very comprehensive bibliography.

The CDC must be a very powerful part of American democracy if they can spend so much effort and money lying to the public about male circumcision. The operation has been entirely discredited as an intervention for reducing HIV and STI transmission, even in African countries that have far more serious HIV epidemics than the one in the US. But it's difficult to imagine why this lie is supported by so many US professionals, academics, institutions and money.

Blinded by Bigotry: Why Researchers May Have Been the Only Ones Surprised by VOICE Trial Failure

The failure of the VOICE pre-exposure prophylaxis trial, daily treatment of HIV negative people with antiretroviral drugs via a vaginal gel, was guaranteed by the long and widely held assumption that almost all HIV transmission in African countries is a result of 'unsafe' sexual behavior.

Participants were deemed to be at risk of being infected with HIV by researchers who had no evidence for this risk. In fact, sexual risk was low, with only one fifth reporting more than one sex partner in the previous three months, low rates of sexual intercourse, very high rates of condom use and fairly low rates of anal sex (which may or may not have involved condoms).

During this trial HIV incidence was very high, 5.7 cases per 100 person years, although it went as high as 9.9 per 100 person years in Durban, a figure that is in urgent need of investigation. Yet, researchers made no effort to find out how the several hundred seroconverting women were infected. There were high rates of certain sexually transmitted infections (though low rates of others); could some women have been infected with HIV as a result of unsafe treatment at an STI clinic?

A whopping 71% of the participants use injectible Depo-provera (DMPA), which is known to significantly increase HIV transmission risk from women to men and from men to women. Two thirds of participants were from Durban, in South Africa's highest prevalence province, Kwa-Zulu Natal. To what extent could this have contributed to these high HIV transmission levels?

It is to be wondered if taking part in this trial could have exposed many women to the risk of being infected with HIV, given that they were selected on the basis that they were currently uninfected and had low sexual risk at baseline.

Whatever the answer to these questions, the unwarranted but ubiquitous assumption that HIV is almost always transmitted through heterosexual intercourse in African countries (but not elsewhere) remains in urgent need of revision. But where does it come from?

UNAIDS, effectively a UN funded lobby for the rich and powerful pharmaceutical industry, bandies the figure about at every opportunity. The claim had been made before this lobby was spawned, but it seems impossible now to identify any body of evidence to support it. Indeed, evidence claimed to support it often suggests the opposite, such as the baseline figures collected by the VOICE study.

Until the HIV industry establish how people are being infected with HIV and employ appropriate (and effective) prevention interventions, high rates of transmission will not stop in African countries. The continued recruitment of vulnerable people in high HIV prevalence areas for trials adminsitrated by researchers who are so entirely blinded by bigotry is inexcusable.

To make matters worse, some are calling for types of monitoring that no longer require them to rely on answers given by participants themselves. This is yet another instance of a 'veterinarian' approach to Africans, similar to the insistence on the utility of injectable Depo-provera (DMPA) in developing countries, despite evidence of harm that even those promoting the drug do not deny.

There is a supremely patronizing article on the trial in the New York Times which, like the researchers, can't accept the possibility that it failed for any other reason than the "elaborate deceptions employed by the women in it". Nothing is said about the elaborate deception of the HIV industry and the researchers eagerly looking for any way of giving pharmaceutical companies the green light to sell ever growing quantities of their grossly overpriced products.

Instead of admitting to any of their obvious failures, researchers are finding ways to get around trial conditions specifically designed to ensure that such trials do not depend entirely on lies and subterfuge in their efforts to find positive results for the various sub-sectors of the HIV industry that stand to benefit most.

Viewed from a different angle, the many rumors that the NY Times article refers to are not surprising, given the experiences of African people countries of unethical practices, harmful procedures, fudged figures for adverse events (or a failure to report them), outright lies told to participants and cover-ups of evident harm to people taking part in trials, and even to people taking various medications.

The issue of payments to participants is briefly discussed (after all, if there's sex there must also be money, right?). One 'global health specialist' says “I’ve never been concerned that money is the factor driving participation or is corrupting the results”. He may like to revise that view during future trials, rather than by further eroding the already weak protection from abuse that participants currently receive.

When a trial fails as miserably as the VOICE trial, researchers need to re-examine some of their most unsupported assumptions, particularly their most bigoted ones. Then they might think twice (or even once) before accusing participants of deception, in addition to promiscuity, lack of understanding, and indifference to the risk of transmitting a deadly disease to their partner and their children.

HIV and Funerals in Kenya: Just add 'Culture' and Stir Vigorously

What probably should have remained someone's blog post about a visit to Western Kenya has been published in the Journal of Public Health. A young woman was taken to a 'disco funeral' in Western Kenya and was told about what happens during such events. The woman goes on to speculate about sexual behavior at funerals, HIV, and possible connections between the two.

However, the article reads like an uncritical and unreflective account of the experience of one white woman being invited to a funeral and attracting the interest of a drunken man while there, and does not seem to shed any light on the possible contribution of 'disco funerals' to HIV transmission, which is probably very small indeed.

The author appears to have believed everything she was told, and even found other published articles to support some of her claims. However, any kind of direct connection with HIV transmission seems tenuous for several reasons:

First, it is claimed that the Luhya of Western province and the Luo of Nyanza province engage in 'disco funerals'. Yet HIV prevalence is several times higher among the Luo than it is among the Luhya.

Second, these practices, as the author goes to some length to explain, take place in remote areas. Yet HIV prevalence is generally much lower in remote areas than it is in towns and cities.

Third, the entire account is anecdotal, it tells us nothing whatsoever about HIV.

Agreed, HIV is sometimes transmitted through unprotected sex, but not always. Evidence of 'unsafe' sexual behavior is not evidence of HIV transmission. Also, evidence of HIV transmission is not evidence of unsafe sexual behavior. The author of the article seems to have accepted both fallacies.

Clearly, there are social problems in these provinces, such as alcoholism, drug abuse, sexual abuse and the like, just as there are everywhere. But what is described in the articles and labelled as a 'cultural practice' sound very much like a funeral (albeit different from what the author may have experienced in Harvard, or anywhere else in the US).

The fact that some people drink too much and engage in various forms of behavior that can carry all kinds of risk, including sexual risk, does not make the events much different from parties, weddings and other get-togethers, that take place in many countries aside from Kenya, perhaps even in the US.

The term 'disco funeral' sounds very much like something made up by a journalist, perhaps similar to the one who wrote an article about this subject in IRIN, a publication that prefers a more sensationalist angle when addressing these 'issues'. But it seems unlikely that identifying social problems associated to a greater or lesser extent with funerals is the key to high HIV prevalence among some tribes in some places and low prevalence among other tribes in other places.

Various sources, apparently including academic journals, seem to publish just about anything about African countries, as long as it contains magic words like 'culture' and 'tradition', and florid descriptions of commonplace practices. But even identifying sexual practices that could be referred to as an aspect of 'culture' or 'tradition' does not necessarily tell us anything about how HIV is being transmitted.