On 16 December, newspapers reported more than 80 residents of a Cambodian village had tested HIV-positive in recent weeks. As of 20 December the reported number testing positive reached 140. Testing is continuing, so that number will likely increase further.
“The crisis began in late November, when a 74-year-old man from Roka tested positive for HIV at the Roka Health Center, according to a statement from Cambodia’s Ministry of Health and the World Health Organization. After receiving the result, the man then sent his granddaughter and son-in-law for testing. They also tested positive for the virus. The man then informed other villagers who had been treated by [an unregistered doctor] to get tested for HIV. After that, the number of cases steadily rose” (quote from: http://www.wsj.com/articles/worries-mount-that-hiv-infections-in-cambodian-village-could-rise-1419062070).
Outbreaks such as this are not unusual (see: http://dontgetstuck.org/cases-unexpected-hiv-infections/). What is unusual is that this one is recognized. It will be even more unusual if it is thoroughly investigated and reported.
An investigation can limit health damage.
1. Limit damage to the victims. Test widely to find as many victims as possible. Then ensure they get good treatment so they can look forward to a near-normal life.
2. Limit damage to others. Investigate to find the specific risks so they can be stopped, not only in this village but in thousands of similar situations in Asia and Africa. Did HIV go through saline infusions, intra-muscular injections, vaccinations, what? When the routes are identified in this outbreak, tell the public at risk in Cambodia and elsewhere so they can help to develop responses to protect themselves and others.
These two challenges can be satisfied with a no-fault investigation. The investigation could be modeled on a truth commission. People who might have been involved in transmission can be asked to cooperate – to report (confess) procedures that might have been unsafe and to report who they treated – in return for a promise not to prosecute.
What can be distracting in an investigation are efforts to pin the blame on one or more people, to put them in prison or sue them. Fear closes doors – what we need are open doors to find what went wrong and fix it. Yes, there is a lot of careless behavior in clinics and hospital – but many who are careless do not realize the risks because they have been confused by lies, eg, that HIV dies in seconds outside the body.
If careless people are to be prosecuted, should we start at the top? Leaders of the health aid industry know health care is often unsafe in much of Asia and Africa and yet support the delivery of invasive procedures without warning the public and without insisting on outbreak investigations to find and stop careless errors. Since it’s unlikely anyone will try to prosecute people at the top, let’s not scapegoat people at the bottom for careless behavior.
A good example of a failed investigation is what happened in Jalalpur Jattan, Pakistan, six years ago (see: http://dontgetstuck.org/pakistan-cases-and-investigations/). In 2008, a local NGO tested 246 people in the community, finding 88 to be infected. This got the attention of Pakistan’s National Institute of Health, which assigned Pakistan’s Field Epidemiology & Laboratory Training Program (FELTP) to investigate, with assistance from the US Centers for Disease Control and Prevention (CDC). The Government charged FELTP to: “determine the extent and chain of transmission” and to “identify…sites of potential transmission.”
FELPT’s investigators did neither. They began with a list of 20 HIV-positive people provided by the government hospital, traced relatives, and looked for people with stigmatized behaviors (sex work, male-male sex, injection drug use). Because the “investigation” did not test the general population it could not determine the extent of transmission or sites of transmission. The report added insult to injury with stigmatizing sexual fantasies: “there may be hidden extramarital and unsafe sexual practices in the community which were difficult to unveil” (see p 51 in: https://dontgetstuck.files.wordpress.com/2012/02/feltp-investigation.pdf).
In Cambodia, let’s hope for an investigation that prioritizes finding and caring for victims (see: https://en-maktoob.news.yahoo.com/families-devastated-cambodia-hiv-outbreak-100523638.html) and preventing more victims – and that does not insult victims with accusations of stigmatized behaviors.