Governments across sub-Sahara Africa support programs – testing partners, etc – to reduce people’s risk to get HIV through sex. Similarly, governments promote programs to protect babies by testing pregnant women and, if HIV-positive, giving them anti-retroviral drugs. Those programs cut sexual and mother-to-child transmission.
But why are so many people still getting HIV?
There’s a good reason: Governments across sub-Sahara Africa have ignored people’s risk to get HIV from skin-piercing procedures – injections, dental care, infusions, manicures, etc. That risk is more important in some communities and facilities than in others. Is it a risk for you? You can see it’s a risk when you hear of one or more unexplained HIV infections in your community – in children with HIV-negative mothers, in virgin teens, or in adults with no possible sexual exposure to HIV.
Investigating unexplained infections is the standard way to find and stop blood-borne transmission and thereby to protect patients. Investigations begin with one or more specific unexplained infections by asking where they came from – what clinic, hospital, or cosmetic service might have reused unsterilized skin-piercing equipment? The next step is to test others who visited suspected facilities; if early testing finds more unexplained infections, testing can be extended to thousands or even tens of thousands to find all infected in the outbreak. Investigators can then work backward from who is infected to zero in on the facilities and procedures infecting patients and/or clients.
Investigations involve a lot of talking and testing, but they are not expensive and do not require experts with rare skills or unusual instruments. The challenges are simple and straightforward: to get healthcare bureaucrats and providers to cooperate; to tell the public that tests are looking for people with HIV from health care; to find and fix dangerous procedures; and, when that’s done, to persuade the public that health care is safe. All that is local. The goal should be prevention not punishment: to educate and alert everyone – providers, patients, clients – to avoid careless errors. A lot of investigating can be done by communities through informal discussions, but thorough investigations need governments to tell their employees – health program managers, hospital staff – to cooperate. In short: African communities and governments can investigate without outside help.
No government in sub-Sahara Africa has investigated any unexplained HIV infection. By not doing so, governments have not been accountable to their citizens – allowing them to get HIV from risks that could and should be found and stopped. Government misbehavior has contributed to disasters. For example, national random sample surveys in Botswana in 2013 and eSwatini (formerly Swaziland) in 2021 found more than 50% of women aged 35-39 years to be HIV-positive; a national survey in South Africa in 2017 found 39.4% of women aged 35-39 years to be HIV-positive. Findings have been even worse in some local surveys, such as 66.4% of women aged 35-39 years and 59.6% of men aged 40-44 years to be HIV-positive in a community in KwaZulu-Natal in 2014. It is unthinkable that governments in Europe or the Americas – and almost anywhere else in the world – would accept such disasters without doing whatever was necessary to protect men, women, and children.
Rephrasing the title of this blog: When will African governments be accountable to protect citizens from blood-borne HIV by investigating unexplained infections? Whatever else might contribute to high HIV prevalence, that is something governments can do to protect citizens.
On the matter of whether or not to investigate, Western governments and institutions have given bad advice to African governments. They have said nothing about investigations as the appropriate and proven response to unexplained HIV infections – such as HIV-positive children with HIV-negative mothers in Kinshasa in 1985. Instead, researchers who saw and reported those 1985 infections advised everyone to accept that unknown numbers of Africans will continue to get HIV from skin-piercing procedures in health care!
Opposition to investigations is seldom stated baldly, as in this 1994 paper by the head of the World Health Organization’s Global Programme on AIDS and future head of UNAIDS: “The media…has helped to increase public awareness about the dangers of nosocomial [in-hospital] transmission. But the short-term benefits of increased public awareness [after a 1988-89 investigation in Russia] may not always be positive. The current outbreak of diphtheria in Russia… has been blamed in part on publicity surrounding [investigated] nosocomial HIV transmission in southern Russia and other problems in the health-care system, which are thought to have discouraged mothers of young children from seeking immunizations from a health-care system that they perceived to be unsafe.”
Can governments in sub-Sahara Africa reject Western governments’ advice to ignore and not to investigate unexplained infections? I am hopeful: I see two ongoing economic and geopolitical shifts reducing Western governments’ influence:
* Economic growth in sub-Sahara Africa year-by-year reduces foreign aid as a percentage of African government budgets. As that percentage drops, African governments are better able to reject donors’ advice.
* The world is shifting from a uni-polar to a multi-polar order. BRICS countries (Brazil, Russia, India, China, South Africa), especially, are challenging United States’ (US) efforts to lead a uni-polar world. In 2023, the BRICS partnership attracted new members, while the US squandered international goodwill and influence by financing war in Ukraine and ethnic cleansing in Gaza. China leads one of the new poles in the emerging multi-polar world. Other influential countries, Russia, India, Germany, Japan, Indonesia, etc, may short- or long-term join one or another bloc. A multi-polar world lets aid-receiving countries (most of sub-Sahara Africa) balance one donor against others. This flexibility lets African governments be more accountable to their citizens and less accountable to any donor.
I am hopeful these shifts will allow African governments to be more accountable to their citizens and, specifically, to investigate unexplained HIV infections.
Bloodborne HIV: Don't Get Stuck! 