Bloodborne HIV: Don't Get Stuck!

Protect yourself from bloodborne HIV during healthcare and cosmetic services

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).

Global Health Tears the World a New One


The Felicific Calculus used by international institutions and global media has decreed that all the bad things in the world, whomever or whatever may have been blamed for them in the past, are now almost entirely accounted for by Covid-19. The world of ordinary people knows that the calculus is a hoax, and that poverty, sickness, disability, economic and environmental collapse, anything that is getting worse since the pandemic started, are a result of the response to it, not the pandemic. 

The English Guardian churns out another clickbait article, deeply concerned about the effects of Covid-19, seemingly oblivious to the fact that every item ticked off in their spreadsheet predates the virus by decades, even centuries. Other media have jumped in with organ trafficking, persecution of people with HIV, family planning provision, availability of sanitary pads, teen pregnancy, child abuse, domestic abuse, female genital mutilation (sic), child marriage, orphans and much else, striving to update their advocacy with the latest hashtags. 

And the universal solution to all these problems is technology! There are vaccines, masks, hand sanitizers, handheld computers and anything else that can be sold to people who have lived their whole lives without access to running water, an adequate and varied diet, in environments that have been depleted, to a large extent, by the same countries that produce all the technology and the purported solutions and their array of placebo suppositories. 

For the Guardian, decades of progress on extreme poverty is now in reverse due to Covid, so the title goes. But much of the ‘evidence’ for this is from a World Bank wonk, who pours out the usual sanctimonious spiel about all the great things that have been achieved, but that are now threatened by a pandemic. They are not threatened by a pandemic, they are threatened by the response to it. 

Bear in mind, this is the institution to which almost every poor country is in debt. Much of those countries’ annual earnings is sent to repay loans they have been persuaded to take over a period of several decades. A handful of international institutions have pushed poor countries to reduce public sector employment, spending on health, education, infrastructure and social services. Indeed, they have ensured the destruction of the very things that they now claim are vital to address Covid-19: hospitals, schools, infrastructure and social services. 

Poor countries are arm-twisted by such international institutions into handing over all resources that are of value to multinationals. Multinationals are not content to rip out everything they can get their hands on, but will happily destroy environments, communities, water supplies, economies and anything else, and leave behind an enormous tab for the host to pay. The very means to survive for most people, fertile land, water, food, employment, agriculture, etc., are denied to those countries in the name of modernization and development. 

The World Bank knows more than most about the conditions in poor countries, because they have spent so long reducing struggling economies to rubble. Countries that had anything worth exploiting were, effectively, colonized by poverty profiteers, people who were paid to take what they wanted, and often took a lot more. Media, like the Guardian, dutifully cover ‘disasters’ as if the damage they wreak on increasingly vulnerable populations is entirely unforeseen, unpredictable, an ‘act of God’. 

Since when has the World Bank been the go-to source of ideas for reducing poverty, or for improving the conditions that most people in the world live in? The countries that have followed their ideologies, as they gradually moved from the vile and despotic policies of 40 years ago to the most comprehensive and widespread enslavement and subjugation of people living in poor countries that we see today, are the ones suffering the most now. 

The only thing more disgusting than promulgating this kind of poverty porn is the pretence that the English Guardian, the World Bank or any of the other big players in the media, international financial institutions and the development industry have the slightest sympathy for those who suffer most from the conditions that underlie this veneer of humanitarianism and philanthropy.  

If these prognostications from the media are correct, and many things really have improved over the past 30-40 years, then we must return to where we were before the pandemic, and identify what we were doing right, and do more of that. Many things will need to be done differently, and the big players of the past will be reluctant to do anything not in their interest. But these lockdowns are a disaster and must be ended before the damage they are doing becomes irreversible. 

To those who herald in the ‘new normal’, there’s nothing new about poverty, disease, food shortages, droughts and disasters. Lockdowns exacerbate and further institutionalize phenomena that have been around for as long as people in poor countries can remember. There’s nothing new about authoritarianism, but we have been happy to overlook it when it was imposed on distant countries. It now threatens everyone and it’s not something to be encouraged. 

In Memory of Dr Joseph Sonnabend, 6 Jan 1933–24 Jan 2021


Dr Joseph Sonnabend’s first concern was always the welfare of his patients, their families and the people they loved. Before HIV was identified as the virus that caused Aids, Dr Sonnabend was treating people suffering from the shocking illnesses that he and others were discovering among their patients in New York, mostly gay men. Many people infected in the 1980s died. But some survived because of the work of professionals such as Joseph. He pioneered safe sex as a response to HIV and Aids among gay men, and gave his patients the undivided attention that few others were prepared to give.

Joseph set up and ran several institutions to address the epidemic, care for sick people and research the disease. But when some of his colleagues joined with other parties to create a myth about an imminent ‘heterosexual Aids’ pandemic in order to raise funding, he left. Joseph was branded a ‘denialist’ by those who didn’t wish to deal with any of the numerous concerns that he raised. However, Joseph continued to insist that you cannot understand the spread of a disease if you fail to identify the most important circumstances surrounding its transmission. He still held his ‘multi-factorial’ view of HIV a few months ago, in a discussion about the history of the pandemic with Sean Strub and Dr. Stuart Schlossman. When Schlossman claimed that no one held such a view any longer, Joseph disagreed, but did not have the opportunity to defend his position at that time.

Joseph told me later that his ‘multi-factorial’ view of disease transmission is a characterization of epidemiology as the study of pathogen, host and environment, and not an idiosyncratic theory of his own. He said that most people he worked with in immunology and epidemiology held a similar view, and did not reduce the explanation of HIV infection and the development of Aids to an account of the pathogen, alone, independent of host and environment factors. That’s why the multi-factorial view of HIV explains a lot more than its sexual transmission among men who have sex with men. The theory can also be used to understand the extraordinary outbreaks of HIV transmission among people who are neither male, gay, intravenous drug users, nor even sex workers. The worst of these outbreaks are all to be found in a few countries in southern and eastern Africa, including Zimbabwe and South Africa, where Joseph spent several decades of his life.

Joseph confirmed my belief that HIV is not ‘all about sex’ in high prevalence countries, and that the worst epidemics cannot be accounted for by alleged ‘unsafe’ sexual behavior among African people. He often asked how women can transmit HIV to men via sexual intercourse, saying he knew of no causal mechanism to explain it. Something about the host and the environment, African people and the conditions they live in, the experiences they have, the diseases they suffer, their crumbling healthcare facilities, their poverty and their position as former possessions of European powers could turn out to be a part of a credible explanation of the highest rates of HIV transmission in the world.

Joseph was concerned about the way people lived, their welfare, their “complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO’s definition of health, not necessarily exemplified by their activities). He was not content with vaccines and cures, treatment regimens and medications, alone. In fact, Joseph was opposed to what he saw as the rapidly increasing ‘medicalization’ of healthcare, and disgusted by the systematic humiliation of African people, who were blamed for their own sickness and told to quietly accept what they were given.

Many people have learned a great deal from Joseph, and benefited from his work. He distanced himself from those who saw HIV and Aids as a launchpad for their own careers and ambitions, and he refused to get involved in the more lucrative side of the pandemic. He will be much missed.

Covid-19: Denialism, Brand of the Cultural Imperialist


The World Peace Foundation should be more circumspect when criticizing a country for its approach to Covid-19. The word ‘denialism’ has a distinctly pejorative use in the selectively diplomatic world of international health. Those using the word see themselves as right, empirically and morally, upholders of the orthodoxy, unassailable. 

The title ‘Tanzania’s Layered Covid Denialism’ is more inciteful than insightful, and calculatedly so. Clearly, the author does not believe there is more than one valid view. If you are not with the orthodoxy, you are against it, an authoritarian, intent on imposing your will on those you lead. 

On the basis of a handful of headline-grabbing titbits, several from Twitter, the author claims that “access to information about Covid-19 has become an elite privilege”.

Let me give you a real example of elite privilege: 

“Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services…use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere;…avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections.” 

Note, the UN believes that their personnel risk bloodborne infections from healthcare facilities available to the public in Tanzania or South Africa. But they insist that those same facilities are safe for people living in those countries, because they claim that almost all HIV transmission is a result of unsafe sex and only a tiny fraction results from unsafe healthcare. 

For all his faults, Thabo Mbeki questioned the view that ‘unsafe’ sexual behavior could explain massive HIV epidemics in a few African countries, but nowhere else. He questioned that old western prejudice about ‘African’ sexual behavior, employed throughout history to justify numerous and lengthy lapses in ethical research and healthcare. 

Sadly, Mbeki was pushed into rejecting the far better supported view that Aids is caused by a virus, HIV. What he should have rejected was the view that HIV is almost always transmitted via heterosexual sex, because outside Africa, it isn’t. 

Mbeki was punished, branded a ‘denialist’, because he didn’t agree with the orthodox view, and said so. The international health community knows that HIV is not commonly transmitted via heterosexual behavior outside of a few African countries. They should have admitted that this serious anomaly tarnishes the entire orthodoxy. 

President Magufuli of Tanzania is certainly not in the same position as Mbeki, because Covid-19 is expected to kill relatively few people, especially compared to numerous pathogens that cause extremely high morbidity and mortality rates in African countries. 

With the economies of Tanzania’s partners under threat, and the strength of the global economy at stake, Magufuli imposed a less stringent lockdown than most other countries. Thankfully, outbreaks of violence, civil unrest, food insecurity and economic collapse seen in countries with similar economies to Tanzania’s were averted. 

Labelling someone a ‘denialist’, whether it’s about HIV or Covid-19, is an unmistakable piece of cultural imperialism. Magufuli’s initial response was entirely reasonable and sensible, more so than those of Kenya, South Africa and many other countries. Since you can’t shame the country into copying an almost global failure to address the virus, maybe you can learn from them?

The Sound of No Hacks Flapping


Silence may have been the most profound contribution to what we know about the Covid-19 epidemic in Tanzania. In fact, silence is the only truly sustainable measure to reduce the onslaught of questionable information emissions during the current infodemic. I hope to hear more of it. 

I am not referring to silence about cases, deaths, lockdown measures, masks and the like. I’m referring to the silence of the media about the terrifying consequences of extreme and irrational lockdowns. Tanzania didn’t follow other poor countries, so they don’t have to face such consequences. 

But there is silence in the mainstream media about the fact that Tanzania is peaceful, the economy is better than most, people are going to work, buying food in the market, agricultural production is little affected and children are going to school, and all because of their moderate response to Covid-19.

The media was all abuzz about what Tanzania’s President Magufuli said about praying and religious devotion, but not his advice about continuing to work, looking after families, sending kids to school and going to hospital in the event of any illness, including, but not limited to suspected Covid-19.

Negative impacts are reported in local Kenyan and Ugandan media, where rash curfews have been brutally enforced by police. But the mainstream media are not interested in that. We hear less about people persecuted, held in unhygienic and insanitary conditions, exposed to numerous health and other risks than we do about Magufuli questioning the efficacy of tests. 

There have been substantial increases in food prices, shortages of staple foods, with many in Kenya and Uganda facing starvation. Kenyan schools will reopen next year, by which time state school pupils will have missed almost a year of schooling. Both countries struggle to maintain law and order and keep their economies afloat.   

Uganda’s President Museveni is less widely quoted, but his only advice to his people was stay at home and pray, nothing else. There are no mainstream media articles about how astute Magufuli has been, nor mention of the moderate lockdown imposed in March, a more moderate one than their neighbors imposed, and for a few months, not indefinitely.   

Does this selective silence in the mainstream media suggest a tacit admission that they were wrong about how poor countries should best address Covid-19, wrong to sneer at Magufuli for his exemplary response, while ignoring the chaos that resulted from neighboring countries’ slavish obedience to wealthy donors?