Bloodborne HIV: Don't Get Stuck!

Protect yourself from bloodborne HIV during healthcare and cosmetic services

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


The ECHO trial (Evidence for Contraceptive Options and HIV Outcomes) was both unethical and useless by design. The trial, reported June 2019, compared three birth control techniques: Depo-Provera (DMPA-IM) injections every three months, an IUD (intrauterine device), and levonorgestrel implants.[1]

  • Research to date has shown that Depo-Provera increases women’s risks to get HIV by 40%-50%.[2,3] By randomizing women to Depo-Provera, the trial violated articles 3, 4, and 9 of the World Medical Association’s Declaration of Helsinki on research ethics (eg, article 9: “It is the duty of physicians who are involved in medical research to protect the life [and] health…of research subjects).”[4]
  • Research to date has shown that birth control pills do not increase women’s risk for HIV.[2,3] By not including birth control pills among the contraceptive methods in the trial, the study violated article 33 of the Declaration of Helsinki (“The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best proven intervention(s)…”).[4]

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.[5]

The ECHO trial could have been both ethical and useful if it had compared birth control options for which there is limited evidence of their impact on women’s HIV risk (eg, IUDs, levonorgestrel implants, and monthly injections of norethisterone enanthate) to birth control pills, for which there is good evidence of little or no impact on women’s HIV risk.[2,3]

As it is, the trial suggests IUDs and levonorgestrel implants likely increase women’s risk for HIV less than does Depo-Provera, if at all. But how did women get HIV: from sex or skin-piercing health care procedures?[6] In countries where skin-piercing health care instruments are unreliably sterile, knowing how women got HIV is relevant for advising them about how to avoid HIV from health care, including skin-piercing birth control options.

Limited information on sexual risks for women in the trial suggests sex caused far less than half of new HIV infections during the trial. During quarterly follow-up visits, 49% of women reported more than 10 sex acts in the previous three months; to err on the high side, I assume all women averaged 15 sex acts per quarter or 60 per year. Fifty-five percent reported no condom use during their last sex act (see Table S11 in [1]). From this I estimate an average of 33 (= 55% x 60) unprotected sex acts per year for all women. I assume 25% of partners were HIV-positive. Using a transmission efficiency of 0.12 per 100 sex acts (from a study in Uganda[7]) I estimate women got HIV from sex at the rate of 1%/year (= 33 unprotected sex acts/year x 25% with an HIV-positive partner x 0.0012 transmissions per HIV-exposed sex act). This is far less than the observed 3.8%/year rate of new infections.[1]

Like many other studies in high-prevalence areas in Africa, the study withholds collected data relevant to assess sexual and non-sexual risks. Encouragingly, the study tested partners for HIV (pp 305-6 in [1]), following recent WHO advice.[8] 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. The study does not report if women who got HIV during follow-up intervals reported any sex acts — with or without HIV-positive partners — during those intervals. This, too, 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…”).[4]

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. not trace and test partners.

Unethical research funded from rich countries has harmed people in less developed countries for decades. The ECHO trial had no problem finding health care professionals willing to do the dirty work and no problem getting ethical approval: more than 750 people collaborated in ECHO research and 13 review boards approved it (supplementary appendix in [1]).

How to stop these outrages? Appealing to courts may get better results than waiting for health care professionals to change. Recently, a United States’ (US) court allowed Guatemalans harmed during medical research to sue private US institutions in US courts.[9] 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: ht; tp://dx.doi.org/10.1016/S0140-6736(19)31288-7; supplementary appendix availabe at: http://echo-consortium.com/wp-content/uploads/2019/06/ECHO-primary-HIV-results-appendix-Lancet-online-first-June-2019.pdf (accessed 28 July 2019)

2. 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).

3. 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).

4. World Medical Association (WMA). Declaration of Helsinki – ethical principles for medical research involving human subjects. New York: WMA, 1964, revised 2013. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ (accessed 26 July 2019).

5. 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).

6. Gisselquist D. Advice to Young Women in Africa: Sex May Not Be Your Biggest Risk for HIV. SSRN, posted 1 May 2019. Available at SSRN: https://ssrn.com/abstract=3381252 (accessed 28 July 2019)

7. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis 2005; 191: 1403-1409. Available at: https://academic.oup.com/jid/article/191/9/1403/860169 (accessed 26 July 2019).

8. WHO. Guidelines on self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: WHO, 2016. Available at: https://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/en/ (accessed 26 July 2019).

9. 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).

 

 

Government of Pakistan protects patients. African governments don’t. Why not?


On 21 July 2019, at an international HIV/AIDS conference in Mexico, Farima Mir reported an ongoing investigation in Ratodero, Pakistan, that has found hundreds of children with HIV from healthcare[1]:

“At the end of April, 46 children in the city tested positive for HIV. And within 2 days, 14 more children were reported in nearby towns. The government mounted a response, screening around 32,000 people… Ultimately, over 770 of the 997 reported new infections were in young children, most from ages 2 to 5 years… Mir said that almost all children who tested positive for HIV had ‘repeated injections for any illness,’ meaning reused syringes were likely to blame.”

What happened in Pakistan echoes what has been found elsewhere, for example, Russia in 1988, Romania in 1989, Libya in 1998, etc (for more information about these and other HIV outbreaks from health care click on “outbreaks and unexpected infections” in the menu at the right of this page).

Almost surely there are many similar outbreaks of HIV from reused and unsterilized syringes, needles, razors, needles and tubes for infusions, and other health care instruments in African countries with the world’s worst HIV epidemics. But no government in sub-Saharan Africa has looked to find and stop HIV from unsafe health care! Whereas Government of Pakistan protects people by investigating unexpected HIV infections, governments of sub-Saharan Africa stick their heads in the sand. How many more people will get HIV from health care in Africa before governments investigate unexpected infections to find and stop the problem?

References

1. Walker M. ‘Man-Made Disasters’ Stymie Progress on Global HIV. Medpage Today 22 July 2019. Available at: https://www.medpagetoday.com/meetingcoverage/ias/81150 (accessed 23 July 2019).

Let’s stop HIV in Africa. What are you waiting for?


Question for African governments: Why haven’t you investigated unexplained HIV infections?

Question for CDC, UNAIDS, WHO: How can you say you want health care to be safe in Africa, but then NOT challenge governments to investigate unexplained infections?

Questions for people living in African: Do you know anyone who is HIV-positive who denies sexual risks? Do you believe them? Have you heard of a child with HIV but with an HIV-negative mother? If they got HIV from health care, you and your loved ones are also at risk. When are you going to ask your government to investigate unexplained infections to find and stop any hospital or clinic that has been infecting patients?

Question for researchers: Why haven’t you tried to find out how people got HIV: trace and test partners: ask where people got skin-piercing treatments?

Question for anyone: Why do you accept racist, sexual fantasies to explain Africa’s HIV epidemics? Yes, sex is a personal risk for HIV, but what is different in Africa that could explain Africa’s terrible HIV epidemics is not sexual behavior but unreliably sterile injections, infusions, and other health care procedures.

Hundreds of children in Pakistan infected by HIV from health care; government investigates to protect children


Beginning end-April 2019, government of Pakistan has been investigating an outbreak of HIV from unsafe health care in Ratodero county. As part of the investigation, government set up camps to test people for HIV. As of 23 May, tests on 20,800 people in Ratodero found >608 to be infected, including >500 children.[1] Almost all HIV-infected children had HIV-negative mothers. 

According to a recent report[2]: “Adviser to the Prime Minister for Health Dr. Zafar Mirza has said that outbreak of HIV in Ratodero has not only shaken the country but entire world adding when he was in Geneva he was also asked about surfacing of HIV… He said root cause of large number of children must be detected… He said federal government along with UNICEF, WHO, UNAID, Aga Khan, Aga Khan University Hospital and other organizations is cooperating with the Sindh government in this connection and they will continue to coordinate till root cause is detected, he added.”

In sub-Saharan Africa, children get HIV from unsafe healthcare, but no government has investigated to protect them

Lots of HIV-positive children with HIV-negative mothers are reported in Africa, but unlike Pakistan, no government has investigated. Nor have WHO or UNAIDS advocated any investigation. Here are some of the many reports of HIV-positive children in Africa with HIV-negative mothers:

* Mozambique, 2015: A random sample national survey found 30 HIV-positive children aged 6-23 months; 10 (33%) of the 30 children had mothers who were HIV-negative.[3]

* Uganda, 2011: A random sample national survey tested adults and children aged 0-5 years for HIV. Based on reports from this survey,[4] an estimated 17% (12 of 70) HIV positive children had mothers who tested HIV-negative (click on “outbreaks and unexpected infections” and then “Uganda” country page).

* Mozambique, 2009: A random sample national survey in 2009 tested children as well as adults for HIV. The study found 63 HIV-positive children aged 0-11 years old, of which 18 (29%) had mothers who tested HIV-negative.[5,6]

* Swaziland, 2006-7: A random sample national survey tested 1,665 mother-child pairs with children aged 2-12 years. Fifty children were infected; 11 (22%) of their mothers tested HIV-negative.[7,8]

WHO’s double standard

WHO’s double standard goes back decades. For example, during 1990-93, WHO’s Global Programme on AIDS coordinated studies in four African countries – Kigali, Rwanda; Kampala, Uganda; Dar es Salaam, Tanzania; and Lusaka, Zambia – to test inpatient children and their mothers for HIV infection. Combining data from the four cities, 61 (1.1 percent) of 5,593 children aged 6-59 months were HIV-positive with HIV-negative mothers.[9] Only three children had been transfused. Although these infections suggested a lot of HIV transmission through unsafe healthcare, WHO, incredibly concluded ‘the risk of…patient-to-patient transmission of HIV among children in health care settings is low.’[10]

At least WHO in 2019 is acting to protect children in Pakistan from getting HIV from unsafe healthcare. Will this ongoing investigation lead WHO to change its long-standing policy of neglect in Africa?

References

1. Masood T. Situationer: dealing with HIV outbreak among children. Dawn 23 May 2019. Available at: https://www.dawn.com/news/1483999 (accessed 24 May 2019).

2. Dawoodpoto J. “HIV in Ratodero has not only shaken the country but entire world.“ Daily Times 24 May 2019. Available at: https://dailytimes.com.pk/399789/hiv-in-ratodero-has-not-only-shaken-the-country-but-entire-world/ (accessed 24 May 2019).

3. page 231 in: Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), e ICF, 2015. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. Rockville, Maryland: ICF, 2018. Available at: https://dhsprogram.com/pubs/pdf/AIS12/AIS12.pdf

4. Table 8.13 in: Uganda Ministry of Health, and ICF International. Uganda AIDS Indicator Survey (UAIS) 2011. Calverton: ICF International, 2012. Available at: https://dhsprogram.com/publications/publication-AIS10-AIS-Final-Reports.cfm(accessed 6 December 2018).

5. pp. 177-181 in: INS, INE, and ICF Macro. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. Calverton, Maryland: ICF Macro, 2010. Available at: http://measuredhs.com/pubs/pdf/AIS8/AIS8.pdf (accessed 19 January 2012).

6. Brewer D. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. Webmedcentral 2011, Article ID WMC002206. Available at: http://www.webmedcentral.com/article_view/2206(accessed 19 January 2012).

7. CSO, eSwatini, and Macro Int. Swaziland Demographic and Health Survey 2006-07. Mbabane, Swaziland: CSO and Macro International, 2008. Available at:  https://dhsprogram.com/pubs/pdf/FR202/FR202.pdf (accessed 8 November 2018).

8. 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); article available at: http://www.interscientific.net/IJSA2009Okinyi.html (accessed 15 October 2018).

9. Hitimana D, Luo-Mutti C, Madraa B, et al. ‘A multicentre matched case control study of possible nosocomial HIV-1 transmission in infants and children in developing countries’, 9thInt Conf AIDS, Berlin 6-11 June 1993. Abstract no. WS-C13-2.

10. Global Programme on AIDS. 1992-1993 Progress Report, Global Programme on AIDS. Geneva: WHO, 1993. p. 85.

Addressing a running sore: HIV in South Africa


Introduction

South Africa, where doctors achieved the first human heart transplant and one of the wealthiest countries in Africa, has a terrible HIV epidemic. In 2015, an estimated 30.8% of pregnant women were HIV-positive at their first antenatal visit, with more pregnant women infected in parts of the country: for example, 44.5% in KwaZulu-Natal province and 48.4% in Zululand district of that province.[1] Even more adults were infected in some age cohorts and regions: for example, in a 2014 survey of a study population in uMungundlovu district, KwaZulu-Natal, more than 66% of women aged 30-39 years were HIV-positive as were 59.6% of men aged 40-44 years.[2] Although South Africa has only 0.75% of the world’s population, a 2017 national survey estimated 7.9 million South Africans infected,[3] more than a fifth of the world’s total HIV infections.[4]

The South African government is doing a lot of what is required to respond to this epidemic with one glaring exception: the government has not investigated any unexpected and unexplained infections (i.e., not from sex, mother-to-child, or injection drug use) to find and stop blood-borne HIV transmission during health care and cosmetic services.

Doing things right: 90-90-90

In 2014, UNAIDS launched the 90-90-90 initiative, setting targets for testing and treatment to be achieved by 2020: 90% of people with HIV know they are infected, 90% who know are on antiretroviral therapy (ART), and 90% on ART have suppressed viral loads.[5]

Government of South Africa has made encouraging progress towards 90-90-90 targets. In a 2017 national survey, 84.9% of HIV-positive adults aged 15-64 years knew they were infected, 70.6% of those who knew were on ART, and 89.5% of people taking ART were virally suppressed. Putting these numbers together, 54% of HIV-positive adults were virally suppressed (54% = 84.9% x 70.6% x 89.5%).[6] The 90-90-90 targets are intended not only to reduce AIDS sickness and deaths but also to reduce HIV transmission. People with suppressed viral loads are not likely to transmit sexually because they have so little virus in semen or vaginal fluids.

Government of South Africa has also done well with prevention of mother-to-child transmission. As of 2017, more than 95% of pregnant women were tested for HIV and those found infected were given ART both to protect them and to prevent HIV transmission to their babies.[4] In 2016-17, less than 1% of HIV-positive mothers transmitted HIV to their babies before and during birth.[7]

Even before the 90-90-90 initiative, government of South Africa in 2010 began an HIV testing campaign, testing 13.3 million people over 18 months, finding 2 million with HIV, and putting 400,000 on treatment.[8] Also in 2010, government told providers to offer an HIV test to anyone seeking health care at a public facility.[9] To make testing easier, government in 2016 approved sale of self-testing kits through private pharmacies and other outlets.[10] These policies and programs support efforts to reach the testing target for 2020 – that 90% of people who are infected know it. More testing contributes to prevention by making it easier for people to know if their (potential) sex partner is HIV-positive, so they know to use condoms or otherwise protect themselves.

Doing things wrong: not investigating unexpected infections

With more testing, treatment, and other factors, the annual number of new HIV infections in South Africa fell 40% from 386,000 in 2010 to 231,000 in 2017.[3] Even so, South Africa’s HIV/AIDS disaster is reaching the next generation: in 2017 young women aged 15-24 years were getting HIV at the rate of 1.5% per year.[3]

The terrible scale of South Africa’s HIV epidemic is due in part to government not doing what it could to protect people. Over the years, public media and medical journals have recognized and reported unexpected HIV infections in South Africa. Nevertheless, as of early 2019, government has not investigated any unexpected infection by identifying suspected source facilities and then tracing and testing others treated at those facilities. For example, beginning in 1999, a group of doctors in Cape Town from time to time asked about and identified possible health care risks for more than 20 HIV-positive children with HIV-negative mothers.[11,12] But government did not subsequently trace and test others treated at suspected source facilities. Without tracing and testing to find others infected at the same facilities it is not possible to determine the extent of any outbreak or to find and fix the specific lapses in standard precautions responsible; and the public remains at risk.

Government of South Africa’s response to unexpected infections contrasts sharply with responses by governments outside sub-Saharan Africa. For example, in 1988 doctors in Elista, Russia (part of the USSR at the time), found and reported unexpected HIV infections in a hospitalized baby with an HIV-negative mother and a blood donor with no sexual risk. Government investigated, testing thousands, tracing transmission from one child directly and indirectly to 265 children in 13 hospitals, and ending the outbreak by August 1989.[13,14] From 1989 through 2014, nine other governments (Cambodia, China, India, Kazakhstan, Kyrgyzstan, Libya, Mexico, Romania, and Uzbekistan) investigated unexpected infections to uncover nosocomial (through health care) HIV outbreaks with more than 100 to more than 55,000 infections [15-17]). Many other governments have investigated unexpected infections to find smaller outbreaks.[16]

A lot of evidence suggests HIV transmission through skin-piercing procedures in health care, and possibly also during cosmetic services, have been and remain common in South Africa. Following paragraphs summarize selected evidence from later to earlier reports.

Incidence in children aged 2-14 years: The fifth South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2017, reported children aged 2-14 years acquired new HIV infections at the rate of 0.13% per year.[6]

Higher HIV prevalence in Black Africans than in other groups: The same 2017 national survey reported much higher HIV prevalence in Black Africans of all ages (16.6%) than in Whites (1.1%), Coloured (5.3%), or Indian/Asians (0.8%).[6] The survey gives no explanation for these differences in terms of sexual behavior. Male circumcision is not a factor: as of 2012, it was more common among Black African adults (52.4%) compared to Whites (23.3%), Coloured (26.4%), or Indian/Asians (33.5%).[18] There is, however, a big difference in where people get health care: in the second national HIV survey in 2005, 80% of Whites reported they usually get health care from private providers, while 80% of Black Africans reported they got most health care from public services.[19]

Unexplained infections in high school women: A 2011-2017 study in Mpumalanga province tested 2,533 high school women aged 13-20 years; 81 were HIV-positive, including 38 who reported never having vaginal or anal sex.[20] The study then followed and retested the women for 1-6 years during which 190 got HIV, including 44 who reported no lifetime sex.[21] At annual surveys during the first three years of follow-up an average of only 9% of women reported any sex without a condom in the previous three months[22]; and from what women reported about partners’ ages (less than 9% were aged over 24 years) less than 10% were HIV-positive.[22,23] Even if all women reporting unprotected sex in the previous three months had unprotected sex 104 times per year (or twice per week; an intended overestimate, considering most were in school), one could expect to see only 0.1% of women get HIV from sex each year, far less than observed incidence of 1.8% per year[22] (0.1% = 9% of women reporting unprotected sex in the previous three months x 104 sex acts per year x 10% of partners are HIV-positive x transmission efficiency of 1 per 1,000 coital acts; the next paragraph references this estimated transmission efficiency)

(This paper estimates transmission efficiencies of HIV through unprotected vaginal sex at 1 per 1,000 coital acts or 10% per year from an infected spouse based on the following references. The United States Centers for Disease Control and Prevention estimates transmission per unprotected coital act at 0.8 per 1,000 from men to women and 0.4 per 1,000 from women to men[24]. A widely cited estimate from a study in Uganda is 1.2 per 1,000 coital acts (with some condom use, which had no impact on estimated transmission efficiency).[25] Six studies in Africa followed discordant couples in which most partners were not aware of their infections or risks and/or did not use condoms; from these six studies both the mean and average rates of HIV incidence in initially HIV-negative partners were less than 10% per year.[26-31] Here and elsewhere I report rates of HIV incidence as percentages per year, a statistic more familiar for non-technical readers than the technical term, infections per 100 person-years.)

HIV-positive virgin men and women: In a 2014-15 survey among adults aged 15-49 years in uMgungundlovu district, KwaZulu-Natal, 11.2% of (self-reported) virgin women were HIV-positive as were 9.0% of virgin men.[2]

Higher incidence in young women than can be explained by sex: Repeated surveys of a study population in mKhanyakude district, KwaZulu-Natal, reported young women aged 15-24 years acquired new HIV infections at the rate of 5.9% per year (486 infections in 8,211 person-years) during 2011-15.[32] Such high incidence is difficult to reconcile with women’s limited sexual exposures to HIV, suggesting most infections come from risks other than sex. In the 2015 survey, 34% (847/2,467) of young women reported at least one coital act without condoms in the previous year,[32] and HIV prevalence was 10% among men who reported sex with a young woman in the past year.[33] Assuming women who reported unprotected sex in the past year averaged 104 unprotected coital acts per year (an intended over-estimate) and a transmission efficiency of 1 per 1,000 coital acts, sex explains incidence of only 0.4% per year, far less than the observed rate of 5.9% per year (0.4% = 34% of women with any unprotected sex in the past year x 104 coital acts per year x 10% of partners were HIV-positive x 0.001 transmissions per unprotected coital act[24,25]).

Cluster of 63 recent and linked infections: The African Health Research Institute found a cluster of 63 very similar HIV (similar sequences of amino acids) in blood collected during 2011-14 from 1,376 adults in a study population in uMkhanyakude district, KwaZulu-Natal. The Institute estimated HIV from one (unidentified) person in mid-2013 was somehow transmitted directly and indirectly over 18 months to 63 men and women.[34] Such fast transmission does not seem possible through sex, with transmission through vaginal sex requiring on average circa 1,000 coital acts; even for receptive anal sex an estimated average of 70 events are required for each transmission.[24] However, such rapid transmission is seen in nosocomial outbreaks; compare, for example, the phylogenetic tree of HIV genetic sequences from an outbreak in Cambodia[35] with the cluster of 63 HIV sequences from KwaZulu-Natal (slide 10 in [34]).

Unexplained infections in pregnant women: Four studies reported numbers of new HIV infections and rates of HIV incidence ranging from 10.7%-11.2% per year (or data to calculate these statistics[36]) in pregnant women during 2002-12. Women would not get HIV through sex at such rates unless all or almost all of their partners were infected. But during those years, less than 15% of adult men in South Africa were HIV-positive[4]; and many HIV-positive married men were married to women who were already infected.[37] The four studies are as follows: Wand and colleagues followed pregnant women in Durban during 2002-5, reporting data to calculate 81 incident infections in pregnant women and incidence of 10% per year[38]; Moodley and colleagues followed pregnant women in Mpumulanga, Eastern Cape, and Free State during 2006-7, observing 72 incident infections and incidence of 10.7% per year[39]; Kharsany and colleagues followed pregnant women in KwaZulu-Natal during 2007-8, observing four incident infections and calculating incidence of 11.2% per year[40]; and Dinh and colleagues reported 212 incident infections in a national sample of pregnant women and data to calculate incidence at 11% per year.[41]

HIV in high school virgin boys and girls: A 2012 survey of students in grades 8-12, averaging 15.8 years old, in KwaZulu-Natal reported 21 (55%) of 38 HIV-positive boys said they were virgins as did 56 (54%) of HIV-positive girls.[42]

HIV incidence in adults with no reported sex risks: The South Africa HIV Prevalence, Incidence, Behaviour and Communication Survey, 2005 (the second such national survey) reported HIV incidence of 1.5% per year in self-reported virgin adults, 2.4% per year in non-virgin adults who reported no sex in the previous year, and a similar 2.4% per year in adults who said they had been sexually active in the previous year.[43]

South Africa’s early epidemic doubles in 9-14 months: At the beginning of the HIV epidemic among Black South Africans in the late 1980s, the number of HIV-positive people doubled in about nine months[44]. During 1990-94, the doubling time for HIV prevalence in pregnant women throughout South Africa averaged 14 months (from 0.7% in 1990 to 7.6% in 1994).[45] The speed of transmission required for such rapid epidemic expansion is much faster can be explained by estimated rates of sexual transmission (1 per 1,000 coital acts or 10% per year between discordant couples[24-31]).

Fixing South Africa’s incomplete HIV prevention program: investigating unexplained infections

South Africa’s promotion of testing and treatment to reach 90-90-90 targets can be expected to slash sexual transmission. As targets are reached, more than 70% (~90% x 90% x 90%) of those infected will have suppressed viral loads and very little risk to transmit to a sexual partner. And with more testing, more people will know if partners are infected, so they will know to be careful.

But 90-90-90 may have less limited impact on blood-borne transmission. Based on outbreak investigations in other countries, blood-borne infections are often found in bunches. For example, HIV went from one in-patient baby to 265 children in 16 months in Russia,[14] from one to 418 infections in 3-4 years in Libya,[46] and from two to more than 200 infections in several years in Cambodia.[35] Large outbreaks characteristically come from facilities giving repeat treatments, where some people infected earlier get another procedure within weeks to month when they have primary infections and high viral loads, making their blood more dangerous and contributing to later transmissions.

The frequent bunching of blood-borne infections from specific facilities means that any identified unexpected HIV infection should be considered – until proven otherwise – to be one of many in an outbreak. When onward transmission occurs within several months, routine testing is not likely to find people with new blood-borne infections before they infect others through the outbreak. Moreover, even if someone tests HIV-positive with a very early infection, if the only risk anyone thinks about is sex, knowing he or she is infected would have no impact on their getting more skin-piercing procedures at the facility that is the source of the outbreak.

Educating health care workers – a continuing effort – has not stopped unexpected infections. Without outbreak investigations, no one knows the specific skin-piercing procedures and facilities responsible for unexpected infections, so there is no way to know where and how to focus efforts to repair dangerous procedures. Investigations in other countries have implicated a long list of health care procedures, including intra-muscular and intravenous injections, flushing intravenous lines, taking medicine from multi-dose vials, dental care, blood tests, blood and plasma donation, and others. Skin-piercing cosmetic procedures, such as tattooing, shaving, and manicures may also be involved.

Getting from no to yes: Officials in the government of South Africa have for decades consistently decided not to investigate unexpected infections. Increasing public awareness of unexpected infections could create public pressure for investigations. Libya and Cambodia provide examples of public pressure successfully pushing governments to investigate.

  • In Libya in August 1998, a magazine reported HIV infections in children traced to the El Fatah Hospital, Benghazi. The government’s initial response was to close the magazine. But parents did not take “no” for an answer. In November 1998 “a group of desperate fathers interrupted a medical conference Ghadafi was attending in Benghazi and appealed to him for help.”[47] Gaddafi ordered treatment for infected children and an investigation that offered HIV tests to all children treated at El Fatah Hospital in the previous year. The investigation found 418 children with HIV from healthcare.
  • In Roka, Cambodia, in November 2014, a 74-year-old man tested HIV-positive. Surprised, he sent his son-in-law and granddaughter for tests; both were infected. More villagers, alerted and worried, went for tests; many found they were infected. Acting on this information, government began an investigation in mid-December. The investigation reported 242 infections, attributing most if not all to skin-piercing procedures from a local private health care provider.[48,49]

With South Africa pursuing 90-90-90 targets, more people are getting tested. In the 2017 national HIV survey, 75.2% said they had ever been tested for HIV, and 66.8% had been tested within the past 12 months.[3] For many South Africans, an HIV-positive test comes as a surprise. In the previous 2012 survey 80% of adults considered themselves at low risk for HIV, giving reasons such as: “I use condoms”; “I abstain from sex”; “I am faithful to my partner.” But many self-assessed low risk adults were infected, accounting for 56% of adult HIV infections (calculated from data in Table 3.56 in [18]). As testing expands, more people are finding themselves with unexpected infections.

What happens next may well depend on whether people who have unexpected infections are able to get a respectful hearing from counselors, the media, churches, lawyers, support groups, non-government organizations, etc. To date, too few of those who manage or participate in public dialogue about HIV have been willing to believe people who report unexpected infections and to push government to mount the proper response to protect public health, i.e., to investigate, to look for outbreaks.

Making investigations work for public health: From a public health point of view, the priority for investigations is to determine the extent of the problem (to find all who were infected in each investigated outbreak) and to identify specific procedural lapses and facilities responsible. What might be ideal under such circumstances is for government to legislate to allow no-fault investigations along the lines of the post-apartheid Truth and Reconciliation Commission.

Attempting to punish or to collect compensation can create situations of conflict in which people who know what happened are motivated not to tell, investigators are pressured not to look, and blame and punishment fall on scapegoats. Open and thorough investigations educate and alert everyone – health care staff, cosmetic service providers, and the public – to be more aware of blood-borne risks. Punishing past mistakes is not necessary to improve health care safety; many health care staff will no doubt be mortified to learn that what they thought was safe may have infected patients. As for compensation, considering decades of inaction and inattention, it is not easy to identify anyone other than the government which both shares responsibility and has resources commensurate with whatever the problem might be. In any case, those who have been harmed already have free treatment.

Public trust in healthcare safety: Although officials have not explained why they have not investigated unexpected HIV infections, one reason may have been to maintain public trust in health care safety. Outbreak investigations that ask former patients at specific facilities to come for HIV tests challenge that trust by making the public aware of possible mistakes. But that is only a short term view of the matter. Acknowledging, investigating, and fixing problems builds trust in the long term.

Conclusion

No one has identified differences in sexual behavior that could explain much higher HIV prevalence in South Africa than in all non-African countries as well as in all but a few regional countries in Africa. One possible explanation is that lapses in health care safety have been driving South Africa’s epidemic. If that is so, then investigations of unexpected infections could lead to a dramatic drop in HIV transmission.

But even if blood-borne risks make only a limited contribution to South Africa’s epidemic, investigations protect public health. According to the World Medical Association’s Declaration of Lisbon on the Rights of the Patient, health care managers and providers have a responsibility to give patients “medical care of good quality” and “health education that will assist him/her in making informed choices about personal health and about the available health services.”[51] Without outbreak investigations, this is not possible.

Similarly, even if blood-borne risks make only a limited contribution to South Africa’s epidemic, investigations that recognize blood-borne transmission at any level undermine the stigmatizing belief that an HIV infection is a sign of sexual behavior.

References

1. National Department of Health (NDoH). The 2015 National Antenatal Sentinel HIV & Syphilis Survey, South Africa. Pretoria: NDoH, 2017.

2. Kharsany ABM, Cawood C, Khanyile D, et al. Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey. Lancet HIV 2018; 5: e 427-e437. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/30021700(accessed 23 October 2018).

3. Human Sciences Research Council (HSRC) Key Findings Presentation: The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communications Survey, 2017. Cape Town: HSRC, 2018. Available at: http://www.hsrc.ac.za/uploads/pageContent/9234/FINAL%20Presentation%20for%2017%20July%20launch.pdf (accessed 30 January 2019).

4. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Geneva: UNAIDS, 2018. Available at: http://www.unaids.org/en/resources/documents/2018/HIV_estimates_with_uncertainty_bounds_1990-2016 (accessed 5 January  2019).

5. UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. 2014. Available at: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf(accessed 19 October 2018).

6. HSRC. HIV Impact Assessment Summary: The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communications Survey, 2017. Cape Town: HSRC, 2018. Available at: http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf (accessed 27 January 2019).

7. Goga A, Chirinda W, Ngandu NK. Closing the gaps to eliminate mother-to-child transmission of HIV (MTCT) in South Africa: Understanding MTCT case rates, factors that hinder the monitoring and attainment of targets, and potential game changers. S Afr Med J 2018; 108: S17-S24. Available at: http://www.samj.org.za/index.php/samj/article/view/12242 (accessed 30 January 2019).

8. Burton R, Giddy J, Stinson K. Prevention of mother-to-child transmission in South Africa: an ever-changing landscape. Obstet Med 2015; 8: 5-12. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934997/pdf/10.1177_1753495X15570994.pdf (accessed 30 January 2019).

9. Pillay Y, White C, McCormick N. How times have changed – HIV and AIDS in South Africa in 2011. S Afr J Med 2012; 102: 77-78. Available at: http://www.samj.org.za/index.php/samj/article/view/5284/3817 (accessed 28 February 2019).

10. Venter F, Majam M, Jankelowitz L, et al. South African HIV self-testing policy and guidance considerations. S Afr J HIV Med 2017: 18, a775. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842980/pdf/HIVMED-18-775.pdf (accessed 31 January 2019).

11. Hiemstra R, Rabie H, Schaaf HS, et al. Unexplained HIV-1 infections in children – documenting cases and assessing for possible risk factors. S Afr Med J 2004; 94: 188-193. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/15098278 (accessed 10 December 2018).

12. Slogrove S, Rabie H, Cotton M. Non-vertical transmission of HIV in children: more evidence from the Western Cape, South Africa. Poster presented at the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention, July, 2011, Rome. Available at (search for Slogrove): http://www.abstract-archive.org/ (accessed 10 December 2018).

13. Belitsky V. Children infect mothers in AIDS outbreak at a Soviet hospital. Nature 1989; 337: 493. Available at: https://www.nature.com/articles/337493a0.pdf (accessed 14 October 2018).

14. 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 (search for “pokrovsky” and find the 12th of 23 appearances; accessed 14 October 2018).

15. Ministry of Health, People’s Republic of China, UNAIDS, and WHO. 2005 update on the HIV/AIDS epidemic and response in China. Ministry of Health, People’s Republic of China, UNAIDS, and WHO. Geneva: UNAIDS, 2006. Available at: http://data.unaids.org/publications/external-documents/rp_2005chinaestimation_25jan06_en.pdf (accessed 12 February 2018).

16. Gisselquist P. Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis & Abbey, 2008. Available at: https://sites.google.com/site/davidgisselquist/pointstoconsider (accessed 30 November 2018).

17. Gisselquist D, Collery S. Unexpected HIV and outbreaks. Don’t Get Stuck with HIV [internet]. WordPress, ND. Available at: https://dontgetstuck.org/kyrgyzstan-cases-and-investigations/ (accessed 29 November 2018).

18. Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence, Incidence, Behavioral and Communication Survey, 2012. Cape Town: HSRC Press, 2014. Available at: http://www.hsrc.ac.za/en/research-data/view/6871 (accessed 5 February 2019).

19. Shisana O, Rehle T, Simbayi L, et al. South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2005. Cape Town: HSRC, 2005. Available at: https://books.google.com/books/about/South_African_National_HIV_Prevalence_HI.html?id=LlZRZjX-D_gC&printsec=frontcover&source=kp_read_button#v=onepage&q&f=false (accessed 30 January 2019).

20. Pettifor A, MacPhail C, Selin A, et al. HPTN 068: a randomized control trial of a conditional cash transfer to reduce HIV infection in young women in South Africa – study design and baseline results. AIDS Behav 2016; 9: 1863-1882. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990514/ (accessed 18 December 2018).

21. Stoner MCD, Nguyen N, Kilburn K, et al. Age-disparate partnerships and incident HIV infection in adolescent girls and young women in rural South Africa. AIDS 2019; 33: 83-91. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30289813 (accessed 3 February 2019).

22. Pettifor A, MacPhail C, Hughes JP, et al. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial. Lancet Glob Health 2016; 4: e978-e988. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626439/ (accessed 18 December 2018).

23. Gomez-Olive FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, et al. Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care 2013; 29: 1122-1128. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778517/ (accessed 15 December 2018).

24. Centers for Disease Control and Prevention (CDC). HIV risk behaviors [internet]. Atlanta: CDC, 4 December 2015. Available at: https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html (accessed 12 December 2018).

25. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: 1149-1153. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11323041 (accessed 12 December 2018).

26. Hugonnet S, Mosha F, Todd J, et al. Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr 2002; 30: 73-80. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/12048366 (accessed7 February 2019).

27. Senkoro KP, Boerma JT, Klokke AH, et al. HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991 through 1996. J Acquir Immune Defic Syndr 2000; 23: 194-202. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/10737435 (accessed 7 February 2019).

28. Wawer MJ, Sewankambo NK, Berkley S, et al. Incidence of HIV-1 infection in a rural region of Uganda. BMJ 1994; 308: 171-3. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542521/ (accessed 7 February 2019).

29. Serwadda D, Gray RH, Wawer MJ, et al. The social dynamics of HIV transmission as reflected through discordant couples in rural Uganda. AIDS 1995; 9: 745-50. Available at: https://www.ncbi.nlm.nih.gov/pubmed/7546420 (accessed 7 February 2019).

30. Carpenter LM, Kamali A, Ruberantwari A, Malamba SS, Whitworth JAG. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999; 13: 1083-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10397539 (accessed 7 February 2019).

31. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342: 921–9. Available at: https://www.nejm.org/doi/10.1056/NEJM200003303421303?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov (accessed 28 February 2019).

32. Chimbindi N, Mthiyane N, Birdthistle I, et al. Persistently high incidence of HIV and poor uptake in adolescent girls and young women in rural KwaZulu-Natal, South Africa prior to DREAMS. PLoS ONE 6 October 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30325932 (accessed 21 December 2018).

33. Doyle AM, Flowy S, Baisley K, et al. Who are the male sexual partners of adolescent girls and young women? Comparative analysis of population data in three settings prior to DREAMS roll-out. PLoS ONE, 28 September 2018. Available at:  https://www.ncbi.nlm.nih.gov/pubmed/30265667 (accessed 21 December 2018).

34. Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions [internet]. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Abstract 47LB. Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&&crd_fl=0&ssmsrq=1522772955419&ctms=5000&csmsrq=5001(accessed 4 April 2018).

35. Black A, Bedford T. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak [internet]. Seattle: Bedford Lab, no date. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/(accessed 15 November 2018).

36. Gisselquist D. Missed signals: not investigating high HIV incidence in pregnant women [internet]. Amsterdam: Social Sciences Research Network, 17 April 2018. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3153795 (accessed 6 February 2019).

37. National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and ICF. South Africa Demographic and Health Survey 2016. Pretoria, South Africa, and Rockville, Maryland, USA: NDoH, Stats SA, SAMRC, and ICF, 2019. Available at: https://www.dhsprogram.com/pubs/pdf/FR337/FR337.pdf (accessed 6 February 2019).

38. Wand H, Ramjee G. Combined impact of sexual risk behaviors for HIV seroconversion among women in Durban, South Africa: implications for prevention policy and planning. AIDS Behav 2011; 15: 479-486. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/20981479 (accessed 28 February 2019).

39. Moodley D, Esterhuizen TM, Pather T, et al. High HIV incidence during pregnancy: compelling reason for repeat testing. AIDS 2009; 23: 1255-1259. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/19455017 (accessed 28 February 2019).

40. Kharsany ABM, Hancock N, Frolich JA, et al. Screening for ‘window-period’ acute HIV infection among pregnant women in rural South Africa. HIV Med 2010; 11: 661-665. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965267/ (accessed 28 February 2019).

41. Dinh T-H, Delaney KP, Goga A, et al. Impact of maternal HIV seroconversion during pregnancy on early mother to child transission of HIV (MTCT) measured at 4-8 weeks postpartum in South Africa 2011-2012: a national population-base survey. PLoS 2015; 10: e0125525. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420458/ (accessed 25 October 2017).

42. Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmissions among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 13 February 2018).

43. Rehle T, Shisana O, Pillay V, et al. National HIV incidence measures – new insights into the South African epidemic. So Afr Med J 2007; 97: 194-199. Available at: http://www.samj.org.za/index.php/samj/article/view/777/247 (accessed 6 February 2019).

44. Padayachee GN, Schall R. Short-term predictions of the prevalence of human iimmunodeficiency virus infection among the black population in South Africa. S Afr Med J 1990; 77: 329-323. Available at: http://archive.samj.org.za/1990%20VOL%20LXXVII%20Jan-Jun/Articles/04%20April/1.2%20SHORT-TERM%20PREDICTIONS%20OF%20THE%20PREVALENCE%20OF%20HUMAN%20IMMUNODEFICIENCY%20VIRUS%20INFECTION%20AMONG%20THE%20.pdf (accessed 29 January 2019).

45. National Department of Health. The 2012 National Antenatal Sentinel HIV & Herpes Simplex Type-2 Prevalence Survey in South Africa. Pretoria: National Department of Health, 2012. Available at: http://www.hst.org.za/publications/NonHST%20Publications/ASHIVHerp_Report2014_22May2014.pdf (accessed 4 February 2019).

46. de Oliveira T, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from a Libyan outbreak, Nature 2006; 444: 836-837. Available at: https://www.nature.com/articles/444836a.pdf (accessed 28 February 2019).

47. Abu-Nasr. AIDS scandal in Libya. CBS News. 20 September 2001. Available at: https://www.cbsnews.com/news/aids-scandal-in-libya/ (accessed 29 November 2018).

48. Pisey H. More than 200 infected in HIV outbreak. The Cambodia Daily 29 December 2014. Available at: https://www.cambodiadaily.com/news/more-than-200-infected-in-hiv-outbreak-74914/ (accessed 29 November 2018).

49. Vun MC, Galang RR, Fujita M, et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. Morbidity and Mortality Weekly Report 2016; 65: 142-145. Available at: http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm(accessed 28 March 2016).

50. World Medical Association (WMA). Declaration of Lisbon on the rights of the patient. Ferney-Voltaire: WMA, 2015. Available at: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ (accessed 11 November 2018).

 

WHO’s early AIDS experts misdirected HIV prevention


Michael Merson, the second head of WHO’s Global Program on AIDS and co-author Steven Inrig describe WHO’s early AIDS response in The AIDS Pandemic: Searching for a Global Response.[1] Unfortunately, their otherwise excellent and detailed history ignores a tragic and continuing failure: the decision by WHO’s experts to accept an unknown  number of HIV infections from unsafe healthcare.

This misdirection has continued. Daniel Fernando reviews the confusion that led to this misdirection in a recent article[2]: “Already by 1985, WHO staff declared ‘Heterosexual promiscuity (large number of partners) is the most important risk factor among adult AIDS patients in Africa.’[quoted from page 9 in reference 3]…If iatrogenic transmissions had been taken seriously and addressed early, HIV in Africa would have been different.” (If you want a pdf Daniel’s article, email him at: dfernando@jjay.cuny.edu.)

In a prominent 1986 paper in the prestigious journal Science, the first head of WHO’s Global Program on AIDS, 1986-91, and the subsequent first director of UNAIDS, 1996-2008, wrote [p 962 in reference 4]: “…one cannot expect public health officials to upgrade blood transfusion services to prevent HIV infection when the proposed intervention is likely to cost, per person, approximately 30 times the annual per capita public health budget. Similarly, one cannot hope to prevent reuse of disposable injection equipment when many hospital budgets are insufficient for the purchase of antibiotics.”

As if this wasn’t enough, when WHO’s experts decided to give a pass to unsafe healthcare in Africa, they didn’t know how serious it would be. There was no evidence at the time – and there still is no evidence – to say with any confidence that blood exposures account for not more than 10% or as much as 50% or 75% or more. The almost exclusive focus on sex was and is based on insufficient evidence.

Although Merson and Inrig recount many events in WHO’s early response to AIDS, they all but ignore what WHO’s experts knew and thought about HIV from unsafe healthcare. The index at the end of the book doesn’t even include these terms: “blood,” “nosocomial,” “iatrogenic,” “injections, medical,” and “scarification.”

Unsafe healthcare was and is the forgotten risk. Africans in large numbers are still getting HIV from this forgotten risk. How many? No one knows.

References

1. Merson M, Inrig S. The AIDS pandemic: searching for a global response. Switzerland: Springer International, 2018.

2. Fernando D. The AIDS pandemic: searching for a global response. J Assoc Nurses AIDS Care 2018: 29: 635-641. Article available by request from Daniel Fernando at: dfernando@jjay.cuny.edu. Abstract available at: https://www.sciencedirect.com/science/article/abs/pii/S105532901830133X?via%3Dihub(accessed 9 January 2019).

3. World Health Organization (WHO). Workshop on AIDS in Central Africa: Bangui, Central African Republic from 22 to 25 October 1985. Geneva; WHO: 1985. Retrieved from http://www.who.int/hiv/strategic/en/bangui1985report.pdf

4. Quinn T. C., Mann J. M., Curran J. W., Piot P. (1986). AIDS in Africa: An epidemiologic paradigm. Science, 234(4779), 955-963. Retrieved from https://doi.org/10.1126/science.3022379.

More unexplained HIV infections in KwaZulu-Natal: time to investigate!


Background: Beginning in 2004, the Africa Health Research Institute in KwaZulu-Natal, South Africa, has been testing a random sample of adults for HIV infection in a study area extending about 21 km x 21 km northwest of Mtubatuba town. The study area has one of the worst HIV epidemics in the world: as of 2014, 36% of women and 27% of men aged ≥15 years were infected (about 9,000 out of 30,000 adults)[1,2].

Recently, the Institute “sequenced” HIV (determined the order of small molecules in each HIV) from 1,376 adults in the study area. From these sequences, the Institute found a group (cluster) of 63 very similar sequences. Because HIV sequences change over time, if a cluster of sequences are almost the same, it means HIV from one person not long ago infected everyone in the cluster.

How long did it take for HIV from one person to infect 63 people? The Institute estimated it took one year only, from mid-2013 to mid-2014 for HIV to pass from one person directly and indirectly (through others, in short transmission chains) to 63 people (see the large cluster in the upper right in slide 10 of Coltart’s 2018 presentation).[3]

To go from 1 to 63 infections in 12 months the number of infections doubled almost 6 times – doubling on average every 2 months from 1 to 2 infections, 2 to 4 infections, etc, to 63 infections. Everything we know about sexual transmission of HIV says sex doesn’t do that! With hetero sex, it takes on average 1,000 coital acts for one person to infect another; that takes a lot more than 2 months. Even for male-male sex, it takes ≥30 penis-in-anus events for one transmission; that also takes time.

Such fast transmission is possible when hospitals or clinics reuse unsterilized skin-piercing instruments. Governments investigating unexplained HIV infections have found such tragedies in Russia, Romania, Libya, and other countries.

The cluster of 63 sequences in KwaZulu-Natal looks like a cluster of sequences from an investigated outbreak in Roka, Cambodia: In late 2014, several residents in Roka, a rural community in Cambodia, found they were HIV-positive although they had no sex risks. The Cambodian government investigated, testing all people in the community. The investigation found 242 HIV-positive residents and traced most infections to injections and other skin-piercing procedures from a local private healthcare provider.

Foreign organizations helping with the investigation sequenced several hundred HIV from the community. Almost all sequences were very similar, showing fast transmission from 1 to 198 infections in a few short years. These sequences can be presented as branches in a “tree” (Figure 1, below[4]). The upper right section of the tree shows the cluster of very similar sequences from Roka. (Most sequences in the lower part of the tree are “controls,” which means the HIV came from other times and places.) The tree shows each HIV infection as the right end-point of a horizontal line. The left ends of these lines show estimated connections to earlier estimated infections. Because the cluster includes very recent infections only, all lines in the upper right are very short. The timeline at the bottom of the figure shows time going from left to right, showing the estimated dates of transmission from earlier to later infections.

Figure 1: Cluster of 198 infections in Roka, Cambodia, linked by transmissions during 2011-14[4]

env_timetree_baltic (1)

If 63 sequences from KwaZulu-Natal came from unsafe healthcare, how many people got infected in the outbreak? The cluster of 63 HIV sequences (see slide 10) is from a 15% sample of HIV-positive adults in the study area (1,347 out of an estimated 9,000 infected adults). If someone could sequence HIV from all 9,000, one could expect to find 420 (= 63/0.15) sequences in the cluster, all from people with new and closely linked infections. Moreover, many of the 63 infections came from Mtubaba town on the southwest edge of the study area. If a hospital or clinic in Mtubatuba town was infecting patients, it’s likely the outbreak also extends south and east of the town. Hence, the number of people infected from whatever caused the cluster might well exceed 1,000. And transmission looked like it was continuing when the Institute collected the last HIV samples it sequenced (see slide 10).

What’s the response to this evidence? Investigating the cluster – to find all who have been infected in the outbreak and to find and stop the sources – is a job for public health. As long as the sources of unexpected infections are not found and stopped, public health should also be warning people about blood-borne risks.

If the South African government were to investigate, what could it do? A first task would be to interview people in the cluster to find where they got health care, dental care, tattooing, or other skin-piercing procedures in 2013-14. Once one or more facilities are identified as the possible sources of at least some infections, public health staff could visit the facilities to look for – and fix – dangerous mistakes. At the same time, government could make a public request for people who got skin-piercing procedures at suspected facilities to come for tests. If someone is infected, start treatment. At the same time, investigators could sequence their HIV to see if it’s similar to HIV in the cluster.

References

1. Vandormael A, Barnighausen T, Herbeck J, et al. Longitudinal trends in the prevalence of detectable HIV viremia: population-based evidence from rural KwaZulu-Natal, South Africa. Clin Infect Dis 2018; 66: 1254-1260. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/29186391 (accessed 16 November 2018).

2. Larmarange J, Mossong J, Barnighausen T, et al. Participation dynamics in population-based longitudinal HIV surveillance in rural South Africa. PLoS ONE 2015; 10: e012345. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0123345 (accessed 16 November 2018).

3. Slide 10 in: Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. 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 4 April 2018).

4. 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). This figure has been copied by permission from Bedford Lab.

Unexplained HIV infections in KwaZulu-Natal: Time to investigate?


It’s decades too late to prevent Africa’s HIV epidemics. But it’s not too late to stop them! When will politicians tell ministries of health to investigate unexpected HIV infections?

There are many places to begin. Here’s one. An article in the journal Lancet HIV, August 2018, reported results from a 2014-15 survey in uMgungundlovu district, KwaZulu-Natal, South Africa.[1] Among women, 44.1% of adults were HIV-positive, including 66.4% of women aged 35-39 years. As for men, 28.0% of adults were infected, including 59.6% of men aged 40-44 years.

Compare this to what happens outside Africa: 0.3% (3 in 1,000) of adults are infected,[2] with infections concentrating in injection drug users and men who have sex with men.

Why do adults in KwaZulu-Natal have hundreds of times more HIV than low risk adults outside Africa? What’s different?

One clue from the survey is that 11.2% of (self-reported) virgin women were HIV-positive, as were 9.0% of (self-reported) virgin men. Another clue is that the percent of young women with HIV increased precipitously: by 34% in 8 years only, from 6.0% at 15-16 years to 40.1% at 23-24 years. The authors want to blame this on sex. But sex can’t explain it: 3/5ths of surveyed women started having sex at age 18 years or later; more than 95% who reported sex in the previous year reported only one partner; and less than 15% lived with a man, making it convenient for them to have frequent sex.

What else could it be? It’s time to take a good look at unexplained HIV (11% of virgin women had unexplained HIV!) to see if such infections came from unsafe healthcare. Beginning in 1988, governments outside Africa have investigated unexplained infections to uncover HIV outbreaks from healthcare with hundreds to thousands of victims.

So far, there have been no such investigations in Africa. But year-by-year, with more HIV testing, more men and women are finding they are HIV positive despite no sex risks. Will increasing public awareness of unexplained infections in KwaZulu-Natal and elsewhere in Africa translate into public demands to investigate?

Finding the hospital or clinic that infected a particular patient is not enough. Once a facility is suspected to have infected one person, it’s important to invite other patients to come for tests, and to report findings to the public. Finding all the people infected in an outbreak can identify unexpected risks. Openness and honesty is the way to go. Telling the public generates support for safe care. Punishing specific healthcare workers can be a distracting witch hunt – in an outbreak, it’s likely many doctors and nurses infected patients due to ignorance, thinking what they did was safe, not from any intent to harm. Finding and fixing mistakes should be the priority.

References

1. Kharsany ABM, Cawood C, Khanyile D, et al. Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey. Lancet HIV 2018; 5: e 427-e437. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/30021700 (accessed 23 October 2018).

2. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Geneva: UNAIDS, 2018. Available at:  http://www.unaids.org/en/resources/documents/2018/HIV_estimates_with_uncertainty_bounds_1990-2016 (accessed 5 January  2019).

AIDS: Prevention of nosocomial infections


Authors: Jäger H, Gisselquist D [this blog was originally posted on 27 July 2018 at: http://www.medizinisches-coaching.net/aids-nosocomial.html%5D

Introduction

Transmission of HIV through health care facilities has been neglected in the fight against HIV/AIDS. The 2018 World AIDS Conference ignored health care risks that have been described in detail for decades (Gonzac 2008Grimm 2011Goldwater 2013), and also outbreak events such as in Cambodia from 2014-2015 (Rouet 2018).

Would it be useful to pay more attention to the subject? ” … the decision of WHO, Western researchers, and the media to ignore the role of reuse of contaminated syringes and needles in health care settings and to instead emphasize African people’s sex with multiple partners was .. critical in the explosion of HIV in Africa … If iatrogenic transmissions had been taken seriously and addressed early, HIV in Africa would have been different (Fernando 2018).”

Why Africa?

Four countries with 0.8% of the world’s population – South Africa, Botswana, Lesotho, and Swaziland – have 21% of the world’s HIV infections (2016 data, UNAIDS 2017). Adult HIV prevalence was 27.2% in Swaziland, 25% in Lesotho, 21.9% in Botswana, and 18.9% in South Africa. In the same year, all of sub-Saharan Africa had 69% of the world’s HIV infections (25.4 of 37.6 million), including 80% of infections in women (14.1 of 17.8 million). HIV not only infects more people in Africa, but also more women: the ratio of women to men with HIV is 1.5 in Africa, whereas in the rest of the world it’s 0.52.

Surveys find sexual behaviour in Africa is similar or safer than in Europe. Can risks other than sex explain why so many people in Africa get HIV?

Lots of evidence says: Yes.

Beginning in the mid-1980s, most official HIV/AIDS experts have ignored abundant evidence unsafe healthcare risks transmit HIV in Africa (Potterat 2016). For example, over 12 weeks in June-August 1985, Project SIDA in Zaire (Democratic Republic of the Congo) tested 258 in-patient children aged 2-24 months at Mama Yemo Hospital in Kinshasa and their mothers for HIV; 32 children were HIV-positive, of which 16 had HIV-negative mothers. The paper that reported these infections noted that children had received injections (p 656, Mann 1986) “in dispensaries which reuse needles and syringes yet may not adequately sterilize their injection equipment.” But there was no investigation – no call for other children to come for tests, and no report of steps taken to prevent future infections.

Another paper by three of the same authors shows the thinking behind the failure to investigate (p 962, Quinn 1986): “one cannot hope to prevent reuse of disposable injection equipment when many hospital budgets are insufficient for the purchase of antibiotics.” In effect, the authors accepted an unknown frequency of nosocomial HIV transmission in Mama Yemo Hospital and elsewhere in Africa. The authors of these two papers include leaders of the international response to AIDS for 22 years: Jonathan Mann led WHO’s Global Program on AIDS during 1986-90; and Peter Piot led UNAIDS during 1995-2008.

Over the years, there has been a continuing flood of evidence for unsafe healthcare and nosocomial HIV transmission in Africa. Jaeger (1991) and N’tita (1991) detailed risks with untested blood and unsterile instruments and procedures. Beginning from 1999, USAID has worked with African governments to survey health facilities: during 2006-15, surveys in six countries in East and Southern Africa reported that 17%-88% (median 68%) of clinics, dispensaries, health centers, and hospitals had equipment to sterilize instruments (USAID no date).

Beginning from 2001, USAID has worked with African governments to test random samples of adults (and sometimes children) for HIV; tests are coupled with questions about sexual behavior. During 2004-15, 11 surveys in Swaziland, Lesotho, Namibia, Zimbabwe, Zambia, and Mozambique reported HIV infections in self-declared virgins: in 11 surveys; across all 11 surveys, 2.2%-5.5% (median 3.6%) of self-declared virgin women and 0.6%-6.7% (median 3.1%) of self-declared virgin men were HIV-positive. In 2006, 22% of HIV-positive children aged 2-11 years in Swaziland had mothers who tested HIV-negative (Okinyi 2009); in Mozambique, 28% of HIV-positive children aged 0-11 years had mothers who tested HIV-negative (USAID no date).

In a 2012 survey of more than 3,000 high school students aged 12->20 years in KwaZulu-Natal, 6.2% of girls and 2.5% of boys were HIV-positive. More than half of the HIV-positive girls and boys said they were virgins (Kharsany, 2014).

A phylogenetic analysis of 1,376 HIV samples collected during 2010-14 from a random sample of adults in KwaZulu-Natal found a large cluster of 75 sequences, including a sub-cluster of more than 60 sequences. Phylogenetic analysis estimated all infections in the sub-cluster were acquired over 12 months from mid-2013 to mid-2014 (Coltart, 2018). Because the study sequenced an estimated 15% of HIV from adults in the community, and because the cluster likely extended beyond the sampled population, the number of infections in the sub-cluster in mid-2014 was likely well over 500; because transmission was ongoing when the samples were collected, whatever was causing the sub-cluster may have continued to infect hundreds more. Rapid transmission within this sub-cluster – much too fast to be explained by sexual transmission – is similar to what investigations have found in nosocomial outbreaks in Russia, Romania, Libya, Cambodia, and elsewhere.

In 2011, Grimm and Class (2011) urged Germany’s Development Bank (KfW) to pay attention to evidence “an important share of new infections in high prevalence settings occurs through blood exposures in formal and informal healthcare,” and called for “interventions targeted to strengthening the health care system in general and infection control in particular.”

When asked on 22 December 2017, what conclusions KfW drew from that paper, Patrick Rudolph, Sector Policy Unit Health & Social Protection, KfW, responded on 19 January 2018: “… In South Africa – currently the only country in which the fight against HIV is the focus of German development cooperation in the health sector – the focus is clearly on preventing the sexual transmission of the pathogen …” But how can he be so sure that HIV proliferation in South Africa can only be explained by sexual activity?

Apart from risky sexual contacts, people in Africa as well as in other countries with less intense generalized HIV epidemics face many other risks, including:

  • Unsterile and often unnecessary medical procedures
  • Cosmetic services, traditional markings and mutilations in girls and boys
  • Depo-Provera (DMPA) for birth control, which increases women’s risk to acquire and to transmit HIV (Hapgood, 2018); 70% of DMPA in Africa was delivered within the framework of development cooperation.
  • Campaigns to circumcise millions of men in Africa (Howe 2011) despite evidence of high risk for surgery in Africa (Weisser, 2008; Biccard, 2018).

Aside from HIV, skin-piercing procedures with unsterile instruments are responsible for almost all of Africa’s heavy burden of hepatitis C virus (HCV) infections. Treatment alone will not solve Africa’s burden of HCV disease. WHO’s strategy to treat HCV will enrich Gilead and some health institutions, but lower HCV incidence will be, at best, modest if “bad medicine” and “drug addiction” are not targeted — eradicated or at least reduced.

What to do to slow HIV and HCV transmission in Africa?

WHO and other international health organizations should urge African governments to:

  • discourage unnecessary injections, surgery, transfusions and other skin piercing procedures;
  • strengthen quality control, including especially reliable sterilization of reused skin-piercing instruments;
  • educate the public about dangers from unsafe and unnecessary healthcare.

A key component of both healthcare quality control and public education about risks is to investigate adverse events – such as suspected nosocomial HIV and HCV infections — and to report findings to the public. Investigations trace and test patients attending hospitals and clinics suspected to be responsible for nosocomial infections. Governments of Russia (1988-89), Romania (from 1989), China, Kazakhstan, Kyrgyzstan, Libya (from 1998), Cambodia (2014-15), and other countries investigated suspected nosocomial infections to find hundreds to thousands of infections (see summaries and references in: Gisselquist 2007; Gisselquist no date).

To date, no government in sub-Saharan Africa has investigated suspected nosocomial HIV infections to see if they are part of an outbreak. This has been a huge mistake.

Links

References

Did dirty healthcare infect a lot of people in KwaZulu-Natal?


For decades, researchers have not been able to explain how so many people in Africa could be getting HIV from sex. At the same time, researchers and public health managers have been ignoring evidence a lot of HIV infections don’t come from sex. For example, a survey of students in five high schools in Vulindlela subdistrict in KwaZulu-Natal, South Africa, reported 56 (54% of) 104 HIV-positive girls said they were virgins; and so did 21 (55%) of 38 HIV-positive boys.[1] Instead of believing students, the study team suggested students lied about being virgins.

Some new evidence may be harder to sweep under the rug. First some explanation of what this evidence shows. Each HIV is a large molecule made of thousands of parts (smaller molecules). Over time, these parts change little by little. Researchers can take HIV from anyone and “sequence” it to determine its parts. After taking HIV from a lot of people,  they can do a “phylogenetic analysis,” looking for similarities among HIV from different people. Very similar HIV can show one person very likely infected the other. If two HIV are less similar, transmission may have happened a long time ago, or may not have been direct, but rather through others. With phylogenetic analysis, researchers can draw trees (phylogenetic trees) showing the likely connections among a lot of HIV.

Now the new evidence: In March 2018, a team of researchers from South Africa and the UK reported a study that sequenced more than 1,300 HIV collected from adults in uMkhanyakude District, KwaZulu-Natal Province, South Africa.[2] They were surprised to find a cluster of 75 very similar HIV. Even more telling, most of the links (transmissions) in this cluster occurred during a matter of months in 2014.

Slide 10 in the presentation by Coltart (click here and scroll down to slide 10) shows the portion of their tree that includes this cluster.[2] Each horizontal line represents HIV from a different person. The short vertical lines that connect the horizontal lines show who seems to have infected whom (either directly or indirectly). The timeline on the bottom shows when transmissions likely occurred.

Most people in this cluster got infected in 2014. Such rapid transmission to so many people is what one would expect from a blood-borne outbreak – maybe from a hospital or clinic reusing bloody instruments. Distressingly, neither the presenter at the March 2018 conference nor anyone who asked questions mentioned nosocomial (healthcare) risks. As far as researchers are concerned, it’s all about sex…blaming the victim.

More than a dozen large HIV outbreaks with 100s or more infected by healthcare have been investigated in Asia, North Africa, Latin America, and Central and East Europe (click on “outbreaks and unexplained cases” in the menu on the right). But nobody has investigated any blood-borne HIV outbreak in Africa. Will someone finally wake up and look at what’s happening in KwaZulu-Natal?

In any case, people living in communities with a lot of HIV in Africa should be careful about blood exposures. Make sure skin-piercing instruments are at least boiled. Be aware: you can’t trust the researchers and public health managers to protect you from HIV during healthcare. They have been denying and ignoring the risk…and blaming HIV-positive people for sexual misbehavior.

References

1. Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmission among students. AIDS Res Hum Retroviruses 2014; 30: 956-965, Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 4 April 2018).

2. Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. 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 4 April 2018).