Bloodborne HIV: Don't Get Stuck!

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Living forward – understanding and stopping Africa’s HIV disasters


“And now these three remain: faith, hope and love. But the greatest of these is love.”

Bible, New International Version, 1 Corinthians 13: 13

Introduction: understanding more important than justice

In this blog, I apply 1 Corinthians 13: 13 to Africa’s unnecessary HIV disasters – unnecessary because they have been driven for decades by easily avoidable blood exposures during health care, not by sex (a minor contributor).

Note the verse says nothing about justice. In the case of Africa’s HIV epidemics, going for justice can be an obstacle to seeing and fixing what went wrong. Going for justice motivates people to hide mistakes, not only from others but also from themselves – not recognizing what they have done and/or inventing excuses to avoid self-judgment. (Personal note: Considering what I’ve done over 75 years, I’d rather have mercy than justice anytime.)

Instead of going for justice, let’s have hope and faith that people will see and fix errors. Love looks forward – wanting people to be healthy in body and spirit. Justice looks backward.

I say this to introduce a fairly simple issue: Explaining what went wrong to cause Africa’s HIV epidemics. It’s not possible to explain what went wrong without saying people made mistakes – in effect, blaming them for causing Africa’s disasters. But my blaming here is intended simply to explain what happened, and does not ask for justice.

Thumbnail sketch of errors that cause Africa’s HIV epidemics

The crucial error that allowed Africa’s HIV disasters was not warning people about HIV from bloodborne risks. For the sake of understanding how that error led to Africa’s HIV epidemics, it’s useful to consider several groups:

  • The source of misinformation: Beginning in the mid-1980s experts in WHO and in African and foreign governments and universities who were trained to understand disease transmission and charged to explain Africa’s HIV epidemics betrayed their training and ethical responsibility. Instead of explaining Africa’s epidemics, they promoted a specific and deadly double standard: Assuring Africans their health care was safe enough for them, but warning foreigners to avoid skin-piercing procedures in Africa. Continuing this double standard for more than 35 years, public health experts leading the international response to Africa’s HIV epidemics have neither warned Africans about risks to get HIV from medical procedures, nor done what is necessary to find and stop bloodborne transmission.
  • Infecting patients: Following bad expert advice, thousands of front-line health staff in Africa unknowingly infected patients through procedures they thought were safe, but were not. Some surely recognized infections best explained by unsafe health care, but did not push for investigations to find their source, accepting experts’ assurances that such infections were rare.
  • Spreading misinformation and stigma: Following and believing bad expert advice, millions of teachers, reporters, NGO staff  and others disseminated misinformation – encouraging people to trust unsafe heath care and stigmatizing HIV-positive youth and adults for imagined sexual misbehavior.
  • Parallel human rights failure: Beginning in the 1980s, human rights experts and organizations accepted the above double standard (health care safe enough for Africans, but not foreigners) as well as HIV-related research that violated established ethical guidelines. Human rights experts should have called out bad advice that killed Africans, but they didn’t.

How understanding what happened can help stop Africa’s HIV epidemics

The way to stop bloodborne HIV transmission is simple and proven: Investigate unexplained infections. As has happened elsewhere, investigations that uncover outbreaks with hundreds to thousands of people with HIV from medical procedures will motivate everyone – including the general public – to do whatever is required to stop bloodborne transmission. That stops Africa’s HIV disasters.

Across sub-Saharan Africa, HIV testing year-by-year exposes unexplained infections in people with no sexual or mother-to-child risks. No doubt  many people who have or know of such infections have talked with friends and neighbors, getting information about other local unexplained infections and considering which clinics or other facilities might have infected them through skin-piercing procedures.

In communities outside sub-Saharan Africa – in Libya, Cambodia, Pakistan, and elsewhere – such informal investigations have gotten into the press and pushed  governments to help with expanded investigations. Building on local informal investigations, governments organized widespread testing, finding more victims and thereby tracing HIV transmission to specific medical facilities and procedures. So far that has not happened in sub-Sahara Africa.

Understanding is important from the bottom up: The more people in the general public are aware of the lies they have been fed – that bloodborne risks infect few Africans – the more likely it will be that they will press reluctant governments to investigate. As people in one community after another ask African governments to help with expanded investigations, and as governments investigate, the truth will overcome experts’ decades of misinformation.

What to do about those who made errors?

Errors caused deaths and sorrows. As of 2022, Africa’s HIV epidemics killed more than 20 million from the time HIV was recognize in the 1980s (see UNAIDS estimates for 1990-2021; warning Africans about bloodborne risks from the mid-1980s could have prevented most of these deaths from bloodborne as well as follow-on sexual and mother-to-child transmission). Tens of millions more are living with infections. Numbers compare with some of the worst wars in history. The human experiences are hard to imagine even person-by-person, much less the scope of the disaster.

Even so: I don’t advocate justice. It wouldn’t bring victims back to life or restore them to health. Most importantly: Going for justice obstructs understanding what went wrong, and thereby blocks finding and fixing errors at all levels – by health bureaucrats, scientists, front-line health staff, and others.

The “ring-leaders” of the misinformation that caused Africa’s HIV epidemics are, as noted above, influential health experts in universities and government organizations. My blaming them for that is not intended to lead to justice. Not going to happen. But understanding who did what might reduce trust and respect for people who  should have known and done better. There are future health policy issues to consider – is it good for health in and out of Africa to trust such people to guide future policies?

With bad information from influential experts, many  people got caught up in the disaster. For example, many front line health staff unknowingly infected patients. It is not possible to find all who did so. Uncertainty is unavoidable. Nevertheless, health staff who understand what happened will be motivated to be more careful in the future, and will save lives with their skills. Self-forgiveness can help them recover and continue to deliver (safe) health care.

As for all others who spread misinformation – they have to learn new stories. It’s been too easy for too many people to fall into moralistic or racist explanations. Lots to do, lots to change.



New evidence bloodborne transmission explains most HIV infections in sub-Saharan Africa  


What new evidence?

            Studies that collect HIV from people in a community and then describe how each person’s HIV is organized (sequence their HIV) can find out how HIV has been spreading in the community. People with similar HIVs very likely have linked infections – one infected the other directly or indirectly (through one or more others). If sex is the most important risk, a lot of sex partners would have similar HIVs. If a lot of people with similar HIVs have no sexual connection, then blood-borne transmission must be infecting a lot of people.

            To see what such studies show about how HIV transmits in Africa, we looked at large studies that collected and sequenced from at least 100 adults in a community-based survey (we included studies that sequenced additional HIV collected during local health activities). Most evidence is recent: 9 of 13 studies meeting those criteria were published in 2017 or later.

New evidence: Not much sexual transmission within households!

            Five of 13 studies give good information about the percentages of HIV infections that may be coming from sex within households. These five studies collected HIV from all willing adults in sampled households and identified couples (spouses, steady partners, or men and women living together) with similar sequences.

            For example, a 2010-13 study in Mochudi town, Botswana, looked for similarities among 833 sequenced HIVs representing half of the HIV-positive adults (age 16-64 years) in the community.[1] The study found 322 sequences similar to one or more others, including 30 in 15 pairs from men and women living together. Assuming they were sex partners (the study does not say one way or the other), one partner likely infected the other, providing a sexual explanation for only 1.8% (=15/833) of Mochudi adults with sequenced HIV.

            The other four studies with information to estimate sexual transmission within households [2-5] identified couples with similar HIV sequences to explain from 0.3% of adults with sequenced HIV in a study area in South Africa up to 7.5% in a study area in Malawi (Figure 1). Some men and women who infected household sex partners may have been missed in these studies (not home, not wanting to give blood, divorced, or died), and studies may have mistakenly said some couples had dissimilar sequences. But even if household sexual transmission was 2-3 times greater than estimated from evidence (Figure 1), it would still account for small percentages of HIV infections in any of the studied communities.

New evidence: Bloodborne transmission dominates outside the home

            None of the articles that met our search criteria identified any short-term sexual partners. Hence, to see the frequency of sexual or blood-borne transmission outside the home we considered the sex of people linked in non-household pairs with similar HIVs. We found five studies that reported the sex of people paired together outside the home (see Table 1). Two of these five studies took HIV from only one adult in each sampled household (7,9), and three identified man-woman household pairs, which we exclude in Table 1.

            If sexual transmission accounts for most infections outside the home, one would expect to see mostly man-woman pairs. On the other hand, if people get HIV from contaminated instruments in health care or cosmetic services, then the previous HIV-positive patient or client whose HIV contaminated the transmitting instrument could be either a man or a women – and one could expect an equal percentage of same-sex vs. men-women pairs. (However, some settings with skin-piercing events might serve mostly one sex, such as antenatal clinics, which could cause some bias towards same-sex pairs outside the home.)

            What do the data show? In three of five studies, same sex pairs account for 59% or more of non-household pairs. Overall, combining data from the five studies, 45% of non-household pairs are same-sex. Near 50% frequency of same-sex non-household pairs suggests that most transmission events outside the home were influenced more by chance (e.g., the last previous patient at a hospital or dental clinic) than by sex.

country, yearsnumber of pairs% same-sex pairs% man-woman pairs
Kenya, 2003-5(6)786%14%
South Africa, 2014-15(7)16859%41%
Uganda, 2009-11(8)2259%41%
Uganda, 2011-1(5)36145%55%
Zambia, 2014-18(9)80442%58%

Similar HIVs in people living too far apart to be sexual partners

            Comparing the locations of two or more non-household adults with similar HIVs and reported or reasonable locations for non-household sex partners undermines the view most infections outside the home come from sexual transmission. Consider evidence from two studies:

  • From HIV collected in Rakai District, 2008-9, similar sequences were more likely to link people from different communities compared to reported non-household sex partnerships. Among clusters (two or more similar HIVs) that linked people outside the home, 72% (=38/53) linked people from two or more Rakai communities, whereas only 28% (=929/3,271) of reported non-household sex partners in the previous year lived in other communities in Rakai District.[4]
  • A study in Botswana in 2013-18 identified 25 (page 20 in[10]) “highly supported probable source-recipient [man-woman] pairs,” which linked men and women living a median of 161 kilometers apart; 1/4th lived at least 420 kilometers apart. Similar sequences in people living so far apart may be better explained by unsafe practices at a hospital or other skin-piercing facility serving a large area than by sexual liaisons.

Large groups of people with similar HIVs from new infections

            Two studies report 63 and 10 people with similar HIVs from new infections. Both studies collected blood from a minority of adults in the study area, so the total number with new and linked infections was likely much larger. But even 63 and 10 new infections are hard to explain by heterosexual transmission (which takes on average years, even between married people unaware one is infected, and with regular unprotected sex). On the other hand, such rapid transmission has been documented in HIV outbreaks from health care in other countries (e.g., Russia[11] and Cambodia[12]).

            Here are some details about these African clusters:

  • A study in KwaZulu-Natal, South Africa, found a cluster of 63 similar HIVs from recent infections. From similarities among sequences, researchers estimated HIV from one person in mid-2013 reached and infected, directly and through others, 63 people over 18 months.[13] This was likely part of a much larger cluster: it was found in HIV representing circa 15% of infected adults in the study area.
  • A study of HIV sequences from villages in southern Cameroon, 2011-13, identified a (page 10 in[14]) “recent transmission” linking 10 women in five villages along a road.

Conclusion: Stopping Africa’s blood-borne HIV transmission

            From this evidence, blood-borne transmission almost certainly accounts for a large proportion, and likely a large majority, of HIV infections in Africa. Stopping bloodborne transmission is the key to stopping Africa’s HIV epidemics.

            Whatever the scale of blood-borne transmission, the best way to stop it is to investigate unexplained infections (e.g., in adults with no sexual risks; in children with HIV-negative mothers), testing widely to find other victims, and thereby trace unsafe procedures. Throughout Africa HIV testing year-by-year exposes thousands of unexplained infections. When people talk within their communities about such infections, that is already an informal investigation. When and if such sharing finds more unexplained infections and focuses suspicions on specific facilities, sooner or later reports reach local media and government officials..

           Will new evidence change anything? If and when African communities start informal investigations into unexplained infections, will new evidence from sequencing encourage government leaders to respond favorably when communities ask for help to find more people infected from the same sources and to trace and stop dangerous procedures?

[Note: this post by Gisselquist and Collery is a short version of their article, which is available for free download on SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4174723.[17] The full article describes the literature search and more details about the new evidence.]

References

1. Novitsky V, Bussmann H, Okui L, et al. Estimated age and gender profile of individuals missed by a home-based HIV testing and counselling campaign in a Botswana community. J Int AIDS Soc 2015; 18: 19918. Available at: https://dash.harvard.edu/bitstream/handle/1/17295521/4450241.pdf?sequence=1&isAllowed=y (accessed 30 May 2022).

2. McCormack GP, Glynn JR, Crampin AC, et al. Early evolution of the human immunodeficiency virus type 1 subtype C epidemic in rural Malawi. J Virol 2002; 76: 12890-12899. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC136717/pdf/1239.pdf (accessed 10 June 2022).

3. Cuadros DF, de Oliveira T, Graf T, et al. The role of high-risk geographies in the perpetuation of the HIV epidemic in rural South Africa: A spatial molecular epidemiology study. PLOS Glob Pub Health 2022; 2: e0000105. Available at: https://journals.plos.org/globalpublichealth/article/comments?id=10.1371/journal.pgph.0000105 (accessed 25 June 2022). Supplementary information available at: https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000105#sec017 (accessed 25 June 2022).

4. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS Med 2014; 11: e1001610. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942316/ (accessed 17 June 2022).

5. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4 (accessed 17 June 2022).

6. Zeh C, Inzaule SC, Ondoa P, et al. Molecular epidemiology and transmission dynamics of recent and long-term HIV-1 infections in rural Western Kenya. PLoS ONE 2016; 11: e0147436. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752262/pdf/pone.0147436.pdf (accessed 25 June 2022).

7. de Oliveira T, Kharsany ABM, Gräf T, et al. Transmission networks and risk of HIV infection in KwaZulu-Natal, South Africa: a community-wide phylogenetic study. Lancet HIV 2017; 4: e41–e50. Available at: https://pubmed.ncbi.nlm.nih.gov/27914874/ (accessed 27 April 2022).

8. Kiwuwa-Muyingo S, Nazziwa J, Ssemwanga D, et al. HIV-1 transmission networks in high risk fishing communities on the shores of Lake Victoria in Uganda: a phylogenetic and epidemiologic approach. PLoS One 2017; 12: e0185818. Available at:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638258/ (accessed 6 June 2022).

9. Hall M, Golubchik T, Bonsall D, et al. Demographic characteristics of sources of HIV-1 transmission in Zambia. medRxiv [internet] 9 Oct 2021. Available at: https://www.medrxiv.org/content/medrxiv/early/2021/10/07/2021.10.04.21263560.full.pdf (accessed 15 May 2022).

10. Magosi LE, Zhang Y, Golubchik T, et al. Deep-sequence phylogenetics to quantify patterns of HIV transmission in the context of a universal testing and treatment trial – BCPP/Ya Tsie trial. eLife 2022; 11: e72657. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8912920/pdf/elife-72657.pdf (accessed 27 April 2022).

11. Pokrovsky VV. Localization of nosocomial outbreak of HIV-infection in southern Russia in 1988-1989. 8th Int Conf AIDS. 19-24 July 1992; abstract no. PoC 4138. Available at: https://quod.lib.umich.edu/c/cohenaids/5571095.0050.029?rgn=main;view=fulltext  (accessed 28 June 2022).

12. Vun MC, Galang RR, Fujita M, et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. MMWR Morb Mortal Wkly Rep 2016; 65: 142-145. Available at:

13. Coltart CEM, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventionsConference on Retroviruses and Opportunistic Infections, Boston, 4-7 March 2018. Abstract 47LB and oral abstract. Available at: AHRI research at CROI 2018 – Africa Health Research Institute (accessed 1 June 2022).

14. Edoul G, Ghia JE, Vidal N. et al. High HIV burden and recent transmission chains in rural forest areas in southern Cameroon, where ancestors of HIV-1 have been identified in ape populations. Infect Genet Evol  2020; 84: 104358. Available at: https://europepmc.org/article/med/32439500 (accessed 25 June 2022).

Time to let go of sexual fantasies about Africa’s HIV epidemics


For decades, too many experts in health agencies and universities have said most HIV in Africa comes from sex. Some does, of course. But most does not. Blaming sex never fit facts – many, many HIV-positive Africans knew and said they did NOT have any sexual risk. Too many experts didn’t believe them.

Finally, we have new evidence to challenge experts’ sexual fantasies. This new evidence comes from looking at each person’s HIV. It does not[!] depend on what anyone says about their sexual behavior.

Sequencing to see who infected whom

Each HIV is made of small pieces (nucleotides) in a particular order, which is called its “sequence.” HIV sequences change bit-by-bit over time. Comparing HIV sequences from two or more people can show how closely their infections are related. If sequences are very similar, one person likely infected the other.

To see how HIV infections have been moving through a community, researchers can take HIV from lots of people in the community, sequence the HIV they collect, and then look to see who has similar sequences. Similar sequences may be in pairs or in larger groups (clusters) of three or more sequences.

Here’s where it gets interesting for Africa: When a study has sequenced a lot of HIV from a community, those sequences can show how many people got HIV from known sex partners, and how many got HIV from other unidentified risks (sex or blood).

What percentage of HIV infections in Africa come from known sex partners

From 2013-2022, five studies sequenced HIV from hundreds to thousands of people in communities in Africa and said how many pairs of similar sequences came from known sex partners. Across these five studies, the percentages of HIV infections explained by known sex partners ranged from 0.3% to 6.6% (see Figure 1, below). All known sex partners were spouses or steady partners (I include suspected partners living together in these percentages).

Studies no doubt missed some spouses who were not at home or did not want to give a blood sample. And studies did not have information on who was a short-term sex partner. But if sex was responsible for even 1/3rd of HIV infections in these communities, missing spouses and short-term partners would have to infect many times more people than identified steady partners.          

Here’s are some details about what these five studies report (Figure 1, and paragraphs following the figure).

Evidence from Mochudi, Botswana

During 2010-13, researchers collected HIV from more than 1,200 adults in Mochudi, a town north of Gaborone, the capital. They sequenced about 2/3rds of the HIV they collected. Two reports give similar but slightly different information about numbers of infections explained by sex:

  • (a) One study, using 785 sequences from Mochudi, found 191 sequences to be similar to one or more others, including 4 pairs from men and women living together.[1] The study does not say they were sex partners. But assuming they were, the study identified sexual links to explain 4 infections: In each pair, one person likely infected the other, but the study cannot say how the first person in each pair got HIV. Hence, the study identified a sexual source for 0.5% (=4/785) of HIV sampled and sequenced from Mochudi.
  • (b) A second study, using 833 sequences from Mochudi, found 322 to be similar to one or more others, including 15 pairs from men and women living together.[2] The study does not say if they were sex partners. Assuming they were, the study found a sexual source for 15 infections, or 1.8% (=15/833) of HIV sampled and sequenced.

Evidence from KwaZulu-Natal, South Africa

In 2011-14, a study collected HIV samples from more than 5,000 adults in a community in uMkhanyakude, KwaZulu-Natal, South Africa.[3] The study sequenced 1,222 HIV from people with known addresses. Among these 1,222 sequences, the study found 333 that were similar to one or more other sequences. Similar sequences included 4 pairs from men and women living together who were not more than five years apart in age. The study does not say if they were sex partners. Assuming they were, the 4 pairs provide a sexual explanation for 4 infections, or 0.3% (=4/1,222) of HIV sequenced and with information on residence.

Evidence from Rakai, Uganda

Two studies sequenced HIV collected in long-term study communities in Rakai District, Uganda. The two studies collected HIV in different years from some of the same but also some different communities. Here’s what they report about sequences and sex partners:

  • One study sequenced 1,099 HIV collected in 2008-9.[4] The study found 209 sequences to be similar to one or more others, including 51 pairs from known couples (married or stable partners). These 51 pairs provided a sexual explanation for 51 infections, or 4.6% (=51/1,099) of infections with sequenced HIV.
  • The second study sequenced 2,652 HIV collected in 2011-15. The study found 1,334 sequences in clusters (that is, similar to one or more others), including 176 pairs from couples.[5] This provides a sexual explanation for 176 infections, or 6.6% (=176/2,652) of HIV sequenced.

Let go of sexual fantasies! What next?

For years, experts denied evidence – saying HIV-positive African who said they were virgins or had one HIV-negative lifetime partner were lying about their sexual behavior . But as Figure 1 shows, only small minorities of HIV infections can traced to known sex partners with similar HIV sequences. This evidence cannot be rejected by saying people lied about their sexual behavior.

It’s time to let go of sexual fantasies. And It’s LONG past time to get serious about finding and stopping HIV transmission from careless and unsafe skin-piercing procedures in health care and cosmetic services. How? Investigate unexplained infections (see menu on the right).

References

1. Novitsky V, Bussmann H, Logan A, et al. Phylogenetic relatedness of circulating HIV-1C variants in Mochudi, Botswana. PLoS One. 2013; b: e8059, DOI:10.1371/journal.pone.0080589. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24349005 (accessed 24 July 2017).

2. Novitsky V, Bussmann H, Okui L, et al. Estimated age and gender profile of individuals missed by a home-based HIV testing and counseling campaign in a Botswana community. J Int AIDS Soc 2015; 18: 19918. Available at: https://dash.harvard.edu/bitstream/handle/1/17295521/4450241.pdf?sequence=1&isAllowed=y (accessed 30 May 2022).

3. Cuadros DF, de Oliveira T, Graf T, et al. The role of high-risk geographies in the perpetuation of the HIV epidemic in rural South Africa: A spatial molecular epidemiology study. PLOS Glob Pub Health [internet] 22 Feb 2022 https://doi.org/10.1371/journal.pgph.0000105 Available at: https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000105#sec017 (accessed 13 May 2022).

4. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS 2014; 11: e1001610. Available at: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001610 (accessed 4 June 2022).

2. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4.pdf (accessed 4 June 2022).


Covid-19 provides an opportunity to challenge lies about HIV in Africa


This website is about bloodborne HIV in Africa, not Covid-19 (hereafter: C19). However, because debates about C19 policies include charges of lies, misinformation, and unethical research, C19  debates have parallels with mismanagement of HIV in Africa. Recognizing these parallels could not only call attention to long-term mismanagement of HIV in Africa but also strengthen debates about C19. For example:

1. Government health agencies and critics charge each other with misinformation about C19 issues. Are health  agencies always reliable? Critics could strengthen their case by calling attention to decades of well-documented lies about HIV in Africa. For example:

Lying about bloodborne risks: For decades foreign and international public health agencies have assured Africans they won’t get HIV from health care even though the same agencies warned their employees they could get HIV from clinics serving the African general public (and arranged special, safe facilities for foreigners). All along evidence was available to show that bloodborne risks were a major contributor to Africa’s HIV epidemics (see Chapters 3 and 6 in [1]). We can quibble about the percentages of HIV from health care, but not about the lies and inadequate response to unexplained infections (no investigations to find and stop their source).

Lying that evidence shows sex accounts for most HIV-positive adults: Yes, evidence shows some adults got HIV from sex penile-vaginal sex. But evidence has never been available to show most infections come from sex. To the contrary: the best evidence says only a minority of HIV-positive Africans got it from sex (see Chapters 3 and 6 in [1]). The long-standing lie that most HIV in Africa comes from sex has led to millions of avoidable bloodborne infections, stigmatized HIV-positive adults with changes of sexual misbehavior, and endorsed long-standing racist stereotypes.

Lying to say Depo is safe: WHO and other public health agencies have lied to Africans about Depo-Provera injections for birth control, dismissing evidence they increase risk for women to get HIV by 40%-50% (for evidence and references, see menu on the right of this page).

2. Critics charge that the US National Institute of Health (NIH), Anthony Fauci, and Gates supported unethical research. These charges could be strengthened by noting long-term and repeated foreign support for unethical HIV-related research in Africa. For example (see also Appendix 2 in [1] or the menu on the right of this page):

Following HIV-positive adults who are unaware of their infections (but researchers know!) to watch them infect spouses, get sick, and die.

Following HIV-positive new mothers who are unaware of their infections (but researchers know!) to watch them infect their babies through breastfeeding.

Giving African women a drug known to increase their risk for HIV and following them to see how fast they get HIV.

Following and testing young African women twice per week in a community where young women get HIV at high rates to study immune responses to very new infections, but without identifying the sources of the new infections, which could protect women in the community.

Where are we going?

Critics of C19 policies challenge official C19 statements and recommendations. Are critics right or wrong? I expect time will tell. But in the meantime, debates  about C19 present an opportunity to recognize and challenge dangerous and demeaning HIV-related public health lies and unethical research afflicting Africans.

Is this a parallel?

After WWII, German Pastor Martin Niemoller confessed that his silence about early government abuses led to more widespread abuses[2]. Here’s a paraphrase of his famous confession – linking HIV lies to current C19 debates:

First they lied to Africans that they would not get HIV from healthcare, and we didn’t complain – because we didn’t take health care in Africa.

Then they followed HIV-positive Africans without telling them they were infected to watch infect their spouses and children, and we didn’t complain — because we didn’t live in Africa.

Then they didn’t warn African women about Depo injections increasing their risk to get HIV, and we didn’t complain -– because we didn’t live in Africa.

Then they asked people in rich countries to believe whatever they said about C19 – and who will help us challenge unreliable official data, analyses, and public health messages (behavior change communications)?

References

1. Gisselquist D. Stopping Bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available for free download at: https://sites.google.com/site/davidgisselquist/stoppingbloodbornehiv (accessed 28 January 2021).

2. Marcuse H. Martin Niemoller’s famous quotation: “first they came for the communists…” Niemoller Quotation Page [internet] 22 April 2021.  Available at: https://marcuse.faculty.history.ucsb.edu/niem.htm (accessed 18 December 2021). Niemoller’s confession: First they came for the socialists, and I did not speak out — because I was not a socialist. Then they came for the trade unionists, and I did not speak out — because I was not a trade unionist. Then they came for the Jews, and I did not speak out — because I was not a Jew. Then they came for me — and there was no one left to speak for me.

Please don’t bother me with facts, I like my sex fantasies!


Sex, sex, sex. Beginning in the late 1980s, several years after HIV was recognized in Africa, health bureaucrats, staff, and researchers have peddled salacious and racist fantasies that almost HIV-positive adults got it from sex.

But what about facts?

One way to see how people in a community have been getting HIV is to see who has viruses that are similar. Because HIV changes over time as it multiplies in anyone it infects, when two people are found to have very similar HIV (similar components in a similar order), one likely infected the other. Studies that look for people with similar HIV in African communities provide facts to test the fantasy that male-female sex accounts for almost all HIV-positive adults.

Here’s an example: During 2011-15, research staff drew blood from 25,882 people in 40 communities in Rakai District in Uganda.[1] More than 5,000 were HIV-positive. Researchers were able to describe HIVs (what components, what order) from 2,552 HIV-positive adults. Among the 2,552 HIV, researchers found 537 pairs with very similar HIV (“highly supported phylogenetic linkages”[page 5 in reference 1]), indicating that one person in the pair likely infected the other.

What do those pairs tell us about sexual fantasies?

1. Setting aside 176 spouse pairs with similar HIV (more on spouses below), there were 361 (=537-176) very similar non-spouse pairs. Here’s where the fantasy runs afoul of facts: 161 (45%) of those 361 non-spouse pairs were same-sex pairs, linking a man with a man, or a woman with a woman. Since the sex of whoever infected anyone seems to have been irrelevant (near equal numbers of same-sex pairs as male-female pairs), the obvious conclusion is that most transmission had nothing to do with sex. Most infections likely came from bloodborne risks such as unsterilized needles, syringes, catheters, saline bags, razors, lancets, etc., not from a sex partner. What about the 200 (=361-161) unmarried male-female pairs? Since the study says nothing about the sexual behavior of anyone in those non-spouse pairs, supposing sexual transmission is based on sex fantasy, not evidence.

2. What about spouses with similar HIV? The study collected and described HIV from 331 husband-wife couples. Only 176 (53%) of the 331 couples had similar HIV. Almost half of the couples (155 of 331) had non-matching HIV, which means husbands and wives likely got HIV from other blood or sex risks, not from their partners. In other words: Sexual transmission seems to be inefficient and slow in Africa as it is elsewhere in the world.

Instead of acting like scientist (respecting evidence), the research team that reported the above facts simply rejected same-sex pairs as mistakes: We don’t like the facts, so we ignore them! Let’s stick with sex fantasies! For example:

Example  1: In a 2021 sub-study, the research team used male-female pairs previously identified to fantasize about the ages of men and women having sex, ignoring same-sex pairs.[2] Because the average HIV-positive man is older than the average HIV-positive woman, one could expect pairs to include older men and younger women no matter how one infected the other (sex, or shared skin-piercing instruments). Duh! But the study team opted for sex fantasies: Hah, older men chasing younger women!  

Example 2: To estimate direction of HIV transmission between Rakai’s lakeshore communities and inland communities, the study team rejected 200 same-sex pairs as misleading (not agreeing with sex fantasies). Then, “[w]e further analysed the … male−female linkages to infer the direction of transmission”[page 6 in  reference 3]. Even so, what they found did not agree with sex fantasies – HIV was going from inland communities with lower percentages of adults infected to lakeshore communities with higher percentages infected. If it was going by sex, that doesn’t make a lot of sense – in sex partnerships across communities, the transmitting (HIV-positive) partner would more likely come from the lakeshore, where adults were more likely to be HIV-positive. On the other hand, if it were going by bloodborne risks in clinics and cosmetic services in inland communities along main roads, then the direction of transmission makes sense if, as seems likely, people from lakeshore communities visit facilities along major roads. Hence, it’s likely many male-female pairs were linked not by sex but by reused and unsterilized skin-piercing instruments.

Peddling sex fantasies about Africa’s HIV epidemic is not a victimless lie 

1. Sex fantasies distract everyone’s attention from bloodborne risks that people face in clinics and cosmetic services. That leads to infections.

2. Sex fantasies stigmatize HIV-positive Africans. Consider, for example, a woman who tests HIV-positive during antenatal care, and then her husband tests negative. Here’s what those who peddle sex fantasies are, in effect, saying to the husband: “Your wife had a boyfriend and lied about it!” What about a teenage boy or girl testing HIV-positive, or a husband? All slimed with abusive fantasies.

3. Health pros who push these fantasies suffer as well. If they know it’s a lie, how do they live with themselves? If they are too scared to investigate unexplained infections to find and stop unsafe practices in healthcare, how can they respect themselves and their profession?

References

1. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogeneetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4.pdf (accessed 13 December 2021).

2. Xi X, Spencer SEF, Hall M. Inferring the sources of HIV infection in Africa from deepsequence data with semi-parametric Bayesian Poisson flow models. arXiv [internet] 29 October 2021. Available at: https://arxiv.org/pdf/2110.12273.pdf (accessed 6 December 2021).

3. Ratmann O, Kagaayi J, Hall M, et al. Quantifying HIV transmission flow between high-prevalence hotspots and surrounding communities: a population-based study in Rakai, Uganda. Lancet HIV 2020; 7: e173-e183. Available at: https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC7167508/ (accessed 13 December 2021).

Ignoring children’s HIV risks – is there any good excuse?


In Mozambique, a national survey in 2015 found that a third of HIV-infected children age 6-23 months had HIV-negative mothers.[5] In a national survey in eSwatini in 2006-7, 22% of tested mothers of HIV-positive children age 2-12 years were HIV-negative.[4]

With evidence like that, why does UNAIDS say that 100% of HIV-positive children age 0-14 years got HIV from their mothers?[2] Why do health experts from US and African estimate that 97% of HIV-positive children aged 10-14 years in five countries in southern Africa got HIV from their mothers?[1]

Ignoring unexplained infections — not finding and stopping risks – allows risks to continue and to infect others. Too many foreign and national experts have been doing just that – ignoring unexplained infections.

How do children with HIV-negative mothers get HIV? The answer to that question depends on the time and place. Answers come with on-site investigations to find and stop specific risks. Where people have looked – in countries outside sub-Sahara Africa – investigations have found hundreds to thousands infected from health care procedures. Investigations found and stopped risks – and, most importantly, protected others (see “outbreaks and unexpected infections” in the menu on the right).

Here’s a letter recently rejected by Clinical Infectious Diseases (below).Because UNAIDS, health experts, and journal editors are not warning Africans to find and stop blood-borne HIV risks, it’s up to people at risk to begin informal investigations and to push their governments to join. Africans at risk have been waiting decades for health experts to discover their hearts and to do the right thing.  

REJECTED LETTER: Unexplained HIV infections in children and adolescents in Africa

TO THE EDITOR – In a recent paper, Low and colleagues[1] use data from national surveys in five countries during 2015-17 (eSwatini, Lesotho, Malawi, Zambia, and Zimbabwe) to examine HIV in adolescents aged 10-19 years. Survey data are sufficient to describe short-comings in finding and treating cases: among 707 identified HIV-positive adolescents, 39.1% had not been diagnosed before the survey, and only 47.1% had suppressed viral loads.

On the other hand, survey data are insufficient to determine sources of infections. For example, setting aside 22 adolescents with recent infections, Low and colleagues estimate 71% (485) of the remaining 685 got HIV from their mothers even though only 35% (= 242/685) of their mothers tested HIV-positive. The only other risk identified from the survey was having had sex, which was reported for 22% (= 150/707) of infected adolescents (without attention to partners’ HIV status). Unspecified behavioral risk was reported for 10% (= 72/707) of infections; surveys did not ask about skin-piercing health care or cosmetic services.

Focusing  on children, Low and colleagues’ estimate 97% of infections in children aged 10-14 years came from mothers. Similarly, UNAIDS assumed all infections in children aged 0-14 years came from mothers.[2] On the other hand, Ng’eno and colleagues, with data from a 2012 national survey in Kenya, identified no risk for 4 of 9 HIV-positive children aged 10-14 years.[3]

Table 1: Attributed risks for HIV infections in Africans aged 0-14 years

Source of estimatecountriesages (years)% of infections attributed to mother-to-child transmission
UNAIDS[2]all0-14100%
Low et al[1]eSwatini, Lesotho, Malawi, Zambia, Zimbabwe10-1497%

Low and colleagues’ and UNAIDS’ low estimates of  the percentages non-vertical HIV infections in children disregard relevant evidence. For example: in a 2006-7 national survey in eSwatini, 22% of mothers of HIV-positive children aged 2-12 years tested HIV-negative (among tested mothers only)[4]; and in a 2015 national survey in Mozambique, 33% of mothers of HIV-positive children aged 6-23 months tested HIV-negative.[5] Moreover, many mothers surveyed in eSwatini and Mozambique likely got HIV from infected children (in two studies with relevant data, breastfeeding children infected from health care infected 40% to 60% of their mothers[6]). If Low and colleagues had looked for HIV in children aged 0-9 years in the five surveys they used to study HIV in adolescents, would they have found similar percentages of unexplained infections?

Disputes about estimates are, of course, matters of judgment. But Low and colleagues’ and UNAIDS’ low estimates of non-vertical (unexplained) HIV infections in children arguably support government decisions not to investigate unexplained infections, which is a matter of fact not judgment: governments in sub-Saharan Africa have not investigated unexplained infections. Unexplained infections challenge governments to investigate to find and fix dangerous skin-piercing procedures to protect public health (see, e.g., recent investigations in Pakistan[7] and Cambodia[8]).

Avoidable infections from undiscovered risks are not the only consequences when public health experts overlook unexplained HIV infections. Low and colleagues decry stigma as an obstacle to finding and treating HIV-positive adolescents. Unfortunately, their estimates contribute to stigma: attributing almost all infections to mothers or sex stigmatizes parents of infected children and/or infected adolescents, whether or not sexually active.

References

1. Low A, Teasdale C, Brown K, et al. Human Immunodeficiency Virus Infection in Adolescents and Mode of Transmission in Southern Africa: A Multinational Analysis of Population-Based Survey Data. Clin Infect Dis 2021, 73: 594-604. doi: 10.1093/cid/ciab031. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366830/ (accessed 14 September 2021).

2. Mahy M, Penazzato M, Ciaranello A, et al. Improving estimates of children living with HIV from the Spectrum AIDS Impact Model. AIDS 2017; 31:13–22. Available at: https://pubmed.ncbi.nlm.nih.gov/28301337/ (accessed 24 October 2021),

3. Ng’eno BN, Kellogg TA, Kim AA, et al. Modes of HIV transmission among adolescents and young adults aged 10-24  years in Kenya. Int J STD AIDS 2018; 29:800–5. doi:10.1177/0956462418758115. Available at:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995643/pdf/nihms950188.pdf (accessed 12 September 2021).

4. Okinyi M, Brewer DD, Potterat JJ. Horizontally acquired HIV infection in Kenyan and Swazi children. Int J STD AIDS 2009; 20: 852-857. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19948900 (accessed 27 October 2018). Available at: http://www.interscientific.net/IJSA2009Okinyi.html (accessed 15 October 2018).

5. Mozambique: Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique (IMASIDA) 2015, Supplemental Report Incorporating Antiretroviral Biomarker Results. Maputo: Ministério da Saúde (MISAU) Instituto Nacional de Estatística (INE), 2019. Available at: https://www.dhsprogram.com/pubs/pdf/AIS12/AIS12_SE.pdf (accessed 15 October 2021).

6. Little KM, Kilmarx PH, Taylor AW, et al. A review of evidence for transmission of HIV from children to breastfeeding women and implications for prevention. Pediatr Infect Dis J 2012; 31: 938-942. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4565150/ (accessed 15 October 2021).

7. Ahmed T. Ratodero HIV stats continue to rise 19 months after outbreak. Samaa 1 December 2020. Available at: https://www.samaa.tv/news/2020/12/ratodero-hiv-stats-continue-to-rise-19-months-after-outbreak/ (acessed 12 December 2020).

8. Rouet F, Nouhin J, Zheng D-P, et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin Infect Dis 2018; 66: 1733-1741. Available at: https://pubmed.ncbi.nlm.nih.gov/29211835/ (accessed 24 February 2021).

Africans at risk when health experts ignore unexplained HIV infections


Across sub-Saharan Africa, governments have not investigated unexplained HIV infections (not from sex or mother-to-child). If you know of one or more unexplained infections in your community, you might be at risk to get HIV when you go for health care, manicure, or other skin-piercing procedure. Because governments have not investigated, it’s up to people at risk to start their own informal investigations — asking people in the community if they know of more unexplained infections, and asking if they have any ideas about where doctors or others might be giving skin-piercing procedures with unsterile instruments. Governments will follow and help if people lead.

Failing their duty, government health experts and foreign experts and researchers have ignored evidence of HIV infections from unsafe healthcare. Here’s an example from one of the world’s worst HIV epidemics — in uMkhanyakude district, KwaZulu-Natal Province, South Africa.

In 2019 a random sample of adults in a large mostly rural study area in uMkhanyakude district found 67.5% of women aged 30-40 years to be HIV-positive (see page e972 in reference 5, below). How could so many be infected? For almost two decades, health experts have been surveying and studying people in the district — without ever bothering to investigate unexplained infections, without finding and stopping their source, and without warning people at risk.

Why have health experts been so negligent and careless about public health? Dense, heartless, some other excuse?

In August  2021, I submitted the following short account of evidence of bloodborne HIV transmission in the study area as a letter to the Proceeding of the National Academy of Science. The editor rejected it without explanation.

Submitted and rejected letter: HIV-1 incidence patterns in KwaZulu-Natal

            Dr Akullian and co-authors report large reductions in HIV incidence, especially for young men and women, during 2012-19 in the Africa Health Research Institute’s surveillance area in KwaZulu-Natal, South Africa.[1] Even so, incidence remained high: in 2019, the highest estimated age-specific incidence was circa 4.4% per year for women and circa 2.0% per year for men (see Figure 4C in [1]).

            Although changes in HIV incidence are clear, the reasons for those changes are less well established. Authors ignore the possibility – hypothesis – that non-sexual transmission through skin-piercing procedures in health care and cosmetic services might be making a substantial contribution to incidence in the study area. In ignoring this hypothesis, authors disregard evidence from the study area, including:

            * Unexplained infections: During 2004-15, adults and adolescents who claimed to be virgins accounted for 189 (8%) of 2,367 recognized incident infections (Table 1 in [2]).

            * A cluster of 63 HIV with closely related sequences: Sequence analyses dated the cluster’s most recent common ancestor to June 2013; within 18 months to November 2014, infections from this common ancestor had reached 63 persons (slide 10 in [3]). The speed of transmission required to explain this cluster has been seen in nosocomial outbreaks (e.g., in Cambodia[4]). Moreover, evidence from the study area suggests sexual partner change made little or no contribution to the cluster: only 43 (1.8%) of 2,367 adults with new infections in the study area during 2004-15 reported more than one partner in the previous year (Table 1 in [2]).

            * Incidence too high to be explained by sex: The estimated circa 4.4% per year age-specific peak incidence rate in women in 2019 is greater than could be expected based the estimated percentage of their partners with unsuppressed viral loads: in 2019 <20% of men aged 30-39 years and lower percentages in other cohorts had unsuppressed viral loads (Figure 3A in [5]). In two large studies in Africa that included discordant couples in which many if not most wives did not know their husbands were infected, wives got HIV at rates of 10.5-12 per 100 person-years[6,7]. If women in the study area with sexual exposure to HIV got infected at such rates, one would expect circa 2% incidence per year, far less than peak age-specific incidence. This estimate ignores mitigating factors, such as concordant positive partnerships and condom use (during 2012-17, averages of more than 60% of women and 70% of men reporting condom use[8]).

            It is not possible to explain the above evidence from the study area without the hypothesis that bloodborne transmission is important. Alternately, one could hypothesize that evidence is wrong, and explain how and why that could be so. Researchers’ failure to respect – accept or reject – evidence pointing to bloodborne transmission parallels public health agencies’ failure to investigate unexplained infections: identifying sites with skin-piercing procedures, testing others attending such sites to find more victims, and thereby finding and stopping sources of bloodborne transmission.

References

1. A. Akullian et al. Large age shifts in HIV-1 incidence patterns in KwaZulu-Natal, South Africa. PNAS 118: e2013164118 (2021). [Available at: https://www.pnas.org/content/118/28/e2013164118, accessed 8 September 2021.]

2. A. Akullian et al. Sexual partnership age pairings and risk of HIV acquisition in rural South Africa. AIDS 31: 1755-1764 (2017). [Available at: https://pubmed.ncbi.nlm.nih.gov/28590328/, accessed 8 September 2021.]

3. C. Coltart et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Conference on Retroviruses and Opportunistic Infections, Boston, 4-7 March 2018. Abstract 47LB and oral abstract (2018). [Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&amp;, accessed 8 September 2021.]

4. F. Rouet et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin. Infect. Dis. 66, 1733-1741 (2018). [Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963970/pdf/cix1071.pdf, accessed 8 September 2021.]

5. E. B.  Wong et al. Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study. Lancet Glob. Health 9, e967–76 (2021). [Available at: https://www.thelancet.com/action/showPdf?pii=S2214-109X%2821%2900176-5, accessed 8 September 2021.]

6. T. C. Quinn et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N. Engl. J. Med. 342, 921-929 (2000). [Available at: https://pubmed.ncbi.nlm.nih.gov/10738050/, accessed 8 September 2021.]

7. L. M. Carpenter et al. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 13, 1083-1089 (1999).

8. A. Vandormael et al., Declines in HIV incidence among men and women in a South African population-based cohort. Nat. Commun. 10, 5482 (2019). [Available at: https://www.nature.com/articles/s41467-019-13473-y, accessed 8 September 2021.]

Geologists can’t find sand in Saudi Arabia!


OK, that’s not so. Geologists know there’s sand in Saudi Arabia. But what about health experts not finding HIV infections from health care in Africa?

All the best evidence says blood exposures in health care and possibly also cosmetic services – not sex — have been driving Africa’s HIV epidemics all along. (Yes, this is a controversial statement; so here are details and references[1].) But just like geologists who don’t know there’s sand in Saudi Arabia, health experts have only rarely identified HIV infections from health care in Africa. And when they have found evidence pointing to HIV from health care, they have mostly ignored and/or denied that happened. For example:

  • A self-declared virgin is HIV-positive? Experts say she lied (administering a double stigma – she’s a liar and a slut).
  • Baby is infected but mother not? Experts can’t deny that, so they ignore it.

I post this blog on the 40th anniversary of the first report of AIDS on 5 June 1981.[2] As soon as AIDS cases were discovered in the US, doctors recognized similar cases in Africa. In the 40 years from 1981 to 2021, medical researchers could have found and stopped HIV transmission through hospitals and clinics in Africa. But that hasn’t happened. No government in sub-Sahara Africa has investigated any unexplained HIV infection to find others infected from the same clinics and to find and stop the risks. Just let it happen, in other words.

When HIV transmission through health care has been so common for so long, how can health experts miss it? To miss it, experts have to be either naturally incompetent (simply not up to the job) or professionally incompetent (keeping quiet so as to keep their jobs).

Such consistent and widespread incompetence requires bad international leadership – discouraging people from finding and/or talking about HIV from health care. WHO, UNAIDS, CDC, and leading US and European universities and journals have helped to organize and enforce deliberate incompetence. Too many people have accepted bad leadership. As a consequence, Africans have suffered tens of millions of unnecessary HIV infections.

Finally, to avoid misunderstanding: sex is a risk. But it’s a secondary risk – people who got HIV from unsafe health care can infect unsuspecting sex partners. So: test sex partners for HIV, because you can’t tell from their sexual behavior if they might be infected. But don’t just worry about sex – blood exposures may be your biggest risk.

References

1. See chapter 6 in: Gisselquist D. Stopping Bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available at: https://sites.google.com/site/davidgisselquist/stoppingbloodbornehiv

2. Gottleib MS, Schanker HM, Fan PT, et al. Pneumocystis pneumonia – Los Angeles. Morb Mort Weekly Rep 1981; 30: 250-252. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/june_5.htm (accessed 5 June 2021).

Mistakes explain Africa’s HIV epidemics: Evidence from a double-barreled smoking gun


A recent double-barreled smoking gun calls attention to mistakes that fuel Africa’s HIV/AIDS epidemics.[1] The first smoking barrel is the discovery of an HIV outbreak in South Africa which is best explained by bloodborne transmission during health care.[2] The second smoking barrel is the subsequent silence by public health and HIV/AIDS experts and officials about the likelihood that unsafe health care caused the outbreak. (A “smoking gun” is “an object or fact that serves as conclusive evidence of a crime or similar act…”[3])

First smoking barrel: HIV outbreak in Kwazulu-Natal, 2013-14

South Africa has one of the world’s most intense HIV epidemics with more than 20% of adults infected.[4] Things are even worse in some places: for example, in a large mostly rural study area in KwaZulu-Natal province more than 60% of women aged 30-49 years were HIV-positive in 2016.[5]

In 2010-14, researchers collected HIV from a random sample of adults in the KwaZulu-Natal study area mentioned in the previous paragraph. The team then sequenced 1,376 HIV samples (i.e., determined the order of HIV’s constituent parts). Because HIV changes over time, similar sequences from two or more people suggest recent and close transmission linkages. Among the 1,376 sequences, the study team found a cluster of 63 very similar HIV. The study team estimated that HIV from one person in June 2013 had somehow reached and infected 63 people within 17 months through November 2014.[2]

The cluster reported from the study area is similar to clusters that governments outside sub-Sahara Africa have investigated and traced to unsafe health care. For example, the diagram linking 63 infections in KwaZulu-Natal (see slide 10 in reference [2]) is similar to diagrams linking HIV sequences from outbreaks in Libya in 1995-99 and in Cambodia in 2013-14.[6,7]

Because the 1,376 HIV came from a random sample of an estimated 9% of HIV-positive adults in the study area, the observed cluster of 63 infections may well be 9% of a much larger cluster in the study area. Moreover, because many of the 63 HIV came from a town on the border of the study area, the cluster likely extends outside the area; and transmission appeared to be ongoing when the study stopped collecting HIV samples in 2014.

Because it is almost impossible for such an outbreak to come from anything other than bloodborne transmission, the government of South Africa could protect public health by investigating to find and fix whatever caused it: asking people in the cluster what skin-piercing procedures they received and where during 2013-14, and then inviting others who visited suspected facilities to come for HIV tests. From 1986, at least 11 governments outside sub-Saharan Africa have investigated unexplained HIV infections to find and fix health care procedures that had caused large HIV outbreaks, infecting more than a hundred to as many as 50,000 people in China.[8,9]

The study that reported this KwaZulu-Natal outbreak suggested it might be from sex, but provides no information about sexual risks for anyone in the cluster. In any case, the possibility that sex could transmit HIV from 1 to 63 infections (much less hundreds) in 17 months is vanishingly small, considering:

  • Even between spouses who are unaware one spouse is infected, it takes on average years for one to infect the other. In a 2016 national survey in South Africa fewer than half of men and women with HIV-positive spouses were themselves infected.[4]
  • According to self-reported sexual behavior, having multiple partners had little to do with HIV transmission in the study area. Repeat surveys in the study area during 2004-15 identified 1,265 new HIV infections in adults with information on sexual behavior; only 43 (3.4%) of adults with new infections reported more than one sex partner in the previous year, while 189 (14.9%) said they were virgins (Table 1 in reference [10]).
  • Widely quoted estimates of the risk to transmit HIV through penile-vaginal sex say transmission occurs in fewer than 1 in 1,000 coital acts.[11]

Even if someone, nevertheless, wants to argue or believe that sex could somehow account for all infections in the cluster, bloodborne transmission during health care remains a possible explanation. That possibility challenges the government of South Africa to investigate to protect public health.

Second smoking barrel: Expert and official silence about the likelihood unsafe health care cased the outbreak

Researchers from the African Health Research Institute and the University College London, who collected HIV from the study area in 2010-14, subsequently sequenced HIV samples and discovered the cluster in 2017. They reported their discovery on 5 March 2018 at the Conference on Retroviruses and Opportunistic Infections (CROI) in Boston.[2] Although the cluster suggests unsafe health care transmitted HIV:

  • We have found no evidence government of South Africa has investigated to protect public health.
  • During their 2018 presentation at CROI the research team did not acknowledge the possibility that unsafe health care caused the outbreak, and none of the discussants even mentioned such risks.[2]
  • To the best of our knowledge, as we are writing this more than two years after the cluster was reported in 2018, no expert in HIV sequencing and no official in any international or foreign health organization or agency has publically acknowledged the possibility the cluster comes from unsafe health care.

Considering the many experts knowledgeable about sequencing and about Africa’s HIV epidemics, the fact that no one has said the obvious – that the cluster likely (or at least possibly) comes from unsafe health care – is strong evidence that people are choosing to keep silent. That in turn suggests they are aware of pressures not to say what is obvious. (The only exceptions to this silence are blogs on this website [search “KwaZulu-Natal] and several papers posted on SSRN by the authors of this blog, for example [1]).

Silence is strong circumstantial evidence – smoking gun evidence – that influential officials who control research funds and jobs for people working on HIV do not want them to talk about health care transmitting HIV in Africa. If anyone wants to challenge evidence-based suspicions that organizations such as the United States’ National Institutes of Health enforce such silence, the way forward is not to debate whether that is so but simply to break the silence – to acknowledge the cluster likely came from bloodborne transmission, and to recommend government of South Africa to investigate. Setting aside debate, the priority should be protecting patients and stopping Africa’s epidemics.

Perspective and context: 35 years of evidence and silence about HIV transmission during healthcare in Africa

Genetic evidence from the HIV cluster in KwaZulu-Natal, and subsequent silence about that evidence, are only the latest in decades of evidence and silence about health care transmitting HIV in Africa.[12-14] The double-barrelled smoking gun discussed in this note is remarkable because it involves experts in gene sequencing, a group that has only recently gotten more involved in HIV-related research in Africa and therefore has had no investment or involvement in decades of dismissive silence about unexplained and likely bloodborne HIV infections in Africa (such as HIV-infected children with HIV-negative mothers, HIV-positive virgin men and women).

Those who are silent are not explaining why they are silent. But insofar as Africans are at risk, the reasons for experts’ and officials’ silence is not important. What is called for, to protect Africans at risk, is not to explain why experts and officials are not doing their jobs, but rather to get some investigations underway and to warn Africans about risks to get HIV from health care as long as those risks are not found and fixed.

References

  1. Gisselquist D, Collery S. Africa’s HIV epidemics: Evidence from a double-barreled smoking gun. Social Science Research Network, 1 May 2020. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3590251 (accessed 1 May 2020).
  2. Coltart CEM, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Oral abstract. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&&crd_fl=0&ssmsrq=1522772955419&ctms=5000&csmsrq=5001(accessed 7 March 2020).
  3. Smoking gun. Wikipedia, 5 March 2020, at: https://en.wikipedia.org/wiki/Smoking_gun
  4. ICF. South Africa Demographic and Health Survey 2016. Rockville (MD): ICF, 2019. Available at: https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf (accessed 1 May 2020).
  5. Vandormael A, Akullian A, Siedner M, de Oliveira T, Bärnighausen T, Tanser F. Declines in HIV incidence among men and women in a South African population-based cohort. Nature Comm 2019; 10: 5482. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889466/pdf/41467_2019_Article_13473.pdf (accessed 7 March 2020).
  6. de Oliveira D, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from Libyan outbreak. Nature 2006; vol 444: pp 836-837.
  7. Black A, Bedford T. Roka/HIV/bayesian_timetree: evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/(accessed 15 November 2018).
  8. Gisselquist D. Points to Consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis and Abbey, 2008. Available at: https://sites.google.com/site/davidgisselquist/pointstoconsider (acccessed 1 May 2020).
  9. Gisselquist D, Collery S. Bloodborne HIV: don’t get stuck. no date. Available at: https://bloodbornehiv.com/cases-unexpected-hiv-infections/ (accessed 7 March 2020).
  10. Akullian A Bershteyn A, Klein D, Vandormael A, Barnighausen T, Tanser F. Sexual partnership age pairings and risk of HIV acquisition in rural South Africa. AIDS 2017; 31: 1755-1764. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508850/ (accessed 1 May 2020).
  11. Centers for Disease Control and Prevention (CDC) HIV risk reduction tool. Atlanta: CDC, no date. Available at: https://wwwn.cdc.gov/hivrisk/about_the_data.html (accessed 7 March 2020).
  12. Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161. Available at: http://www.cirp.org/library/disease/HIV/gisselquist1/gisselquist1.pdf (accessed 1 May 2020).
  13. Potterat JJ. Why Africa? the puzzle of intense HIV transmission in heterosexuals. In: Potterat J.J. Seeking the positives: a life spent on the cutting edge of public health. North Charleston (SC): Createspace, 2015. p. 175-229. Available at: https://www.researchgate.net/publication/311993589_Why_Africa_The_Puzzle_of_Intense_HIV_Transmission_in_Heterosexuals (accessed 1 May 2020).
  14. Fernando D. The AIDS pandemic: searching for a global response. J Assoc Nurses AIDS Care 2018; 29: 635-641. Abstract available at: https://www.sciencedirect.com/science/article/abs/pii/S105532901830133X?via%3Dihub (accessed 7 March 2020).

Will women who got HIV during the ECHO trial sue for damages?


More than a dozen studies over decades found that women who used Depo for birth control were more likely to get HIV than women who didn’t use it. Despite that evidence, governments of the US and Sweden, the Bill and Melinda Gates Foundation, and the UN Population Fund arranged and funded the ECHO trial (Evidence for Contraceptive Options and HIV Outcomes).[1]

The ECHO trial randomly assigned more than 7,000 HIV-negative women in eSwatini, Kenya, South Africa, and Zambia to one of three birth control methods: Depo, an intrauterine device, or a hormone implant. During 2015-18, the ECHO trial followed and retested women to see who got HIV.

The trial was unethical: Before the ECHO trial began to enroll women in December 2015, three reviews of accumulated evidence (from 10-18 studies published during 1993-2014) had estimated that Depo use increased women’s risk to get HIV by 40-50%.[2,3,4] Hence, assigning research participants to Depo violated the Declaration of Helsinki’s admonition to “promote and safeguard the health, well-being and rights of patients, including those who are involved in medical research.”[5]

The principle here is “equipoise”: research can be justified in situations where so far we don’t know the answer. But, in this case, we already know the answer. Giving women Depo to watch them get HIV is like asking women to cross streets with their eyes closed to see if they are more likely to get hit by cars vs. women who keep their eyes open.

As for  intrauterine devices and implants (the other two birth control methods in the study), there is not enough information to say what if any impact they have on women’s HIV risk. Similarly, no one can say if monthly injections of NET-EN (norethisterone enanthate) effect women’s HIV risk. The ECHO trial could have been both ethical AND useful if it had tested those methods against a safe option.  And there is a safe option: According to a lot of research, both before and after the ECHO trial began, pills do not increase women’s risk for HIV.[3,6] Hence, the ECHO trial could have tested various birth control methods (but NOT Depo) against pills. Such a trial would satisfy The Declaration of Helsinki ethical guidelines[5]: “The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best proven intervention(s)..”

As it turned out, and as could have been expected, a lot of women got HIV during the ECHO trial — almost 4% per year for all methods. Women taking Depo got HIV a bit faster, at 4.2% per year. Such high rates likely include a lot of infections from bloodborne risks.

The ECHO trial had no problem finding people willing to do the dirty work – to implement unethical research – and no problem getting ethical approval. More than 750 people collaborated in ECHO research and committees at WHO and Columbia University approved it as ethical.[1]

ECHO trial results have been widely misinterpreted. A report of the trial in The New York Times, for example, said the results show Depo-Provera “does not raise HIV risk.” Because the trial did not compare Depo-Provera to pills, it does not support that statement.[7] Just nonsense!

Like many other studies in Africa, the study withholds collected information that is relevant to assess sexual and non-sexual risks. Encouragingly, the study tested partners for HIV (pp 305-6 in [1]), but the study does not say how many partners tested HIV-positive or how much having an HIV-positive partner increased a woman’s HIV risk. Huh, isn’t that relevant to understand what happened?

The study does not report if women who got HIV during follow-up intervals reported any sex acts during those intervals — with HIV-positive partners or with anyone else. Withholding relevant information also violates the Declaration of Helsinki (article 36: “Researchers have a duty to make publicly available the results of their research on human subjects and are accountable for the completeness and accuracy of their reports…”).[5]

Aside from not reporting all relevant collected information, by all accounts the study did not collect other relevant information. Like most other foreign-funded HIV research in Africa, the study ignored non-sexual risks.

How to stop these outrages? Appealing to courts may get better results than waiting for health care professionals to change. Recently, a US court allowed Guatemalans harmed during medical research to sue private US institutions in US courts.[8] Does this mean that any woman in the ECHO trial randomized to Depo-Provera who got HIV during the trial could sue private US institutions involved in the trial in US courts?

References

1. Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 2019; published online June 13. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31288-7/fulltext; supplementary appendix available at: http://echo-consortium.com/wp-content/uploads/2019/06/ECHO-primary-HIV-results-appendix-Lancet-online-first-June-2019.pdf (accessed 24 May 2022)

2. Ralph LR, McCoy SI, Shiu K, Padian N. Hormonal contraception use and women’s risk of HIV acquisition: a meta-analysis of observational studies. Lancet Infect Dis 2015; 15: 181-89. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526270/ (accessed 24 May 2022).

3. Morrison CS, Chen PL, Kwok C, et al. Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis. PLoS Med 2015; 12: e1001778. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303292/ (accessed 26 July 2019).

4. Brind J, Condly SJ, Mosher SW, et al. Risk of HIV infection in depo-medroxyprogesterone acetate (DMPA) users: a systematic review and meta-analysis. Issues in Law and Medicine 2015; 30: 129-138. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=brind+condly+mosher (accessed 5 March 2018). More results from this review are at: Depo-Provera and HIV. PRI, no date. Available at: https://www.pop.org/depo-provera-and-hiv/ (accessed 6 March 2018).

5. World Medical Association (WMA). WMA Declaration of Helsinki – ethical principles for medical research involving human subject, amended October 2013. Ferney-Voltaire, France: WMA, 2013. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ (accessed 24 May 2022).

6. Polis CB, Curtis KM, Hannaford PC, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016; 30: 2665–83. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106090/ (accessed 26 July 2019).

7. McNeil DG. Depo-Provera, an injectable contraceptive, does not raise HIV risk. New York Times 13 June 2019. Available at: https://www.nytimes.com/2019/06/13/health/depo-provera-hiv-africa.html (accessed 27 July 2019).

8. Stempel J. Johns Hopkins, Bristol-Myers to face $1 billion syphilis infections suit. Reuters 4 January 2019. Available at: https://www.reuters.com/article/us-maryland-lawsuit-infections/johns-hopkins-bristol-myers-must-face-1-billion-syphilis-infections-suit-idUSKCN1OY1N3 (accessed 26 July 2019).