Bloodborne HIV: Don't Get Stuck!

Protect yourself from bloodborne HIV during healthcare and cosmetic services

Tanzania and Covid-19: Some Accidental Truths?


A British journalist based in Tanzania claims in The Spectator that the WHO is ‘concerned’ about the government’s lack of transparency during the Covid-19 pandemic. Writing under the pen name ‘Tom James’, the journalist gives the impression that there is an extremely serious Covid-19 outbreak in the country, one that the government is refusing to address.

However, the story is undermined by the journalist’s description of how things are in Dar es Salaam, the country’s biggest city, during this outbreak. For a start, he admits that there is little or no evidence for any deepening crisis, but he continues to write as if the absence of evidence means things must be worse than the government says.

The journalist could return to Britain, although he chooses not to do so (because he wants to look after his dogs). But clearly, things are not so bad that he must leave; he’s got a job and a home; he has a car that he is still able to run, so no fuel shortages; he can go to the market to buy supplies, so no panic buying, hoarding or sudden spikes in prices of staples.

It sounds, if the journalist is to be believed, as if everyone there is just getting on with it. We get a description of normal, everyday life in Tanzania: the police are patrolling the highways, fining people for anything and nothing; a motorbike taxi with three passengers is on the road; only the driver has a mask, but no helmet; again, nothing unusual. What, I’d like to know, would ‘Tom James’ prefer?

The English Guardian claims that Tanzania’s president is undercounting cases and deaths. But the US is overcounting, something the Guardian seems oblivious of; so is the UK, and they are collecting records that cannot be reanalyzed, should anyone ever wish to know the true numbers of cases, deaths and excess deaths.

If President Magufuli is ‘playing down’ the threat of Covid-19, the US and the UK are talking it up (Norway is considering the possibility that their own lockdown was unnecessary).

The media frequently uses the word ‘authoritarian’ when referring to the Tanzanian president. So, what if Magufuli did impose a lockdown? Wouldn’t that be even more authoritarian than not doing so? In most African countries, people can’t just stop working, self-isolate at home, work from home, get their food delivered or hop in their car, unlike the more fortunate ‘Tom James’.

I doubt if he and others criticizing Magufuli would like to see Tanzania follow the example set by Kenya. Human Rights Watch describes a country completely unprepared to ‘isolate’ thousands of possible Covid-19 cases, as unprepared as all poor countries are.

In Kenya, people have been rounded up and held with numerous other people who may or may not have the virus. Even in the UK one doctor writes: “many patients acquired the infection while already hospitalised for other causes“. Infection control in East African hospitals is not great; how much worse will it be in these temporary holding facilities in Kenya?

Kenya imposed a curfew early on in the pandemic and police have been beating people who break the curfew. But, as the Human Rights Watch article shows, conditions in the country don’t allow everyone to drop their normal routines and get home before 7. People can’t easily ‘socially distance’ in overcrowded slums, cramped public transport and other overstretched services.

An article in African Arguments describes just how authoritarian, and how destructive, the lockdown is in Kenya (although the same publication in April called for a lockdown in Tanzania).

Al Jazeera point out that opposition leaders in Tanzania accuse the government of lying about Covid-19 and of failing to address the crisis. But what country’s opposition doesn’t accuse their government of lying and of making unwise decisions? It’s an election year, and Magufuli wants to win, as does the opposition, and these phenomena are not peculiar to Tanzania, nor even to African countries.

Usually the first to shout ‘fire’ in a crowded building (and they have done plenty of shouting about Covid-19 in Tanzania), the BBC has a short piece entitled “Tanzanian doctors ‘not overwhelmed by pandemic‘.” (You need to page down a long way to find it. It’s worth noting that the BBC’s content about Tanzania seems to depend heavily on contributions from the public, social media and other questionable sources.)

One of the worst things that can happen to poor countries during a pandemic is that people panic, as it can bring about the very conditions that will only deepen the crisis. ‘Tom James’ appears to want someone to shout ‘fire’, although he doesn’t quite do it himself. But, however inadvertently, his article suggests that no one in Tanzania is listening to him or his media colleagues. Let’s hope that continues.

Coronavirus Lockdown: Atlas Drugged


The New Humanitarian (formerly the UN’s IRIN) cites a US Embassy Tanzania statement about Covid-19 (C19): “Despite limited official reports, all evidence points to exponential growth of the epidemic in Dar and other locations in Tanzania.”

Think about the first clause, and how it relates to the second, and you may get more than a hint of contradiction. There is no evidence whatsoever pointing to exponential growth of C19 in Dar, Tanzania, East Africa or anywhere else on the continent.

The authors depend on a handful of anonymous ‘doctors’, and on Twitter, to pad out their article. They allude to ‘secret burials’, something we heard about during earlier outbreaks of media scaremongering, such as the 2014 Ebola epidemic in West Africa.

One source says they don’t have enough PPE, another says they do. One says that people are not going to hospitals, which is nothing new. Nor is it even unambiguously worrying; it has long been recognized that hospitals in outbreak areas are among the most likely places to be exposed to Ebola, for example.

Another source says there is no free flow of information, and that’s preventing people from making informed choices. Major international healthcare programs have been run in Tanzania and other developing countries, with little international concern about the issues of free flow of information or informed choices!

Haven’t The New Humanitarians heard of mass male circumcision, injectable Depoprovera, healthcare associated outbreaks of HIV and hepatitis C? Have they ever read any healthcare Service Provision Assessments for African countries, showing how often running water and other hygiene facilities are absent?

The majority of people in poor countries can’t stay at home, work from home or even distance themselves from other people, especially in cities. That’s the way developing countries are. If Magufuli advised people to do any of these things, there would be a lot more confusion than there is now.

Some genuine insights into C19 have been made by Michael Fumento, who has written about many of the major outbreaks, epidemics and pandemics over the last several decades. His recent article entitled ‘The Swedish alternative: Coping with a virus while preserving livelihoods and liberties’ is a good start.

Tanzania and Sweden probably have little in common, but the mainstream media can’t condemn Sweden loudly enough, even though they have full access to data and information; perhaps The New Humanitarian and others can wait until they have access to data and information before publishing sensationalist articles based on gossip and innuendo?

The New Humanitarian article admits: “Amid the swirl of rumours and the absence of reliable news, many businesses have closed their doors. But there is public support for the government’s position not to issue a stay-at-home order.”

An article from Tanzania about Magufuli allows him to explain what he is doing, without comment. Some might say the media in Tanzania have to be careful what they publish. However, media here in the UK has chosen to be especially careful, and none of the more liberal press, particularly The Guardian and the BBC, would dare to deviate from a narrow set of approved mantras.

Some of the conservative media, such as The Telegraph and The Spectator, have taken a more enlightened stance, advising that vulnerable people be protected from C19 and other conditions, but without closing down the entire economy and scaring the shit out of everyone.

Now is not the time for The New Humanitarian to echo and manufacture ‘news’. Tanzania has refused to give in to the international press, institutions and others who have been ‘advising’ them for decades. So let’s wait and see who is right, and not try to bring about the kind of panic and subsequent damage we purport to warn about.

Tanzania’s Magufuli and Covid-19: Justifiably Cautious?


In an article on what Ben Taylor calls ‘Tanzania’s Gamble’, he states that: “We no longer have any reliable estimates of the number of cases or deaths from COVID-19.” True, Tanzania has not carried out many tests. But President Magufuli has asked pertinent questions about how useful the tests are.

Despite carrying out tens of thousands of tests a day, the UK is in a very similar position to Tanzania. This is because they record many deaths that may not be from Covid-19 as if they resulted from the virus, and there is no way of analyzing the figures to work out what proportion is accurate.

In the US, one source has said that the number of deaths ‘from’ Covid-19, as opposed to the number of deaths of people ‘with’ Covid-19 is vanishingly small, probably less than 10%. Presumably we can apply the same comment to recorded cases (link to embedded video: https://tinyurl.com/y83vtm3w).

Some quick comparisons: globally, nearly a million people die of malaria every year. 1.5 million people die of TB. Nearly 800,000 die of HIV, despite enormous sums of donor funding being poured into this single disease. There are no vaccines for any of these diseases, or for most of the big killers, although many are preventable.

Taylor complains of politicization of statistics and media in Tanzania. He writes: “Controlling the narrative means silencing facts that contradict the official line.” Taylor believes that statistics about Covid-19 are no exception. No doubt, Taylor is right.

But the shocking thing in the UK is how few people seem to be questioning the lockdown, the use of figures from a model that has always been wide of the mark in the past, the censorship of social media and the provision of ‘official’ and ‘approved’ versions.

Magufuli is not wrong in claiming that ‘international’ media have often created sensationalist stories about Tanzania and other African countries. Many of these are offensive, demeaning and racist, but you don’t hear the likes of Taylor questioning ‘international’ media, and calling out the lies.

Fear-mongering is not exclusive to African leaders or media. Many of the current lockdowns in the UK, US and elsewhere are based on making people feel afraid to go about their normal day to day lives; they are made to feel ashamed if they have the temerity to ‘contravene’ government guidelines in the slightest way.

According to Taylor, Magufuli has “emphasised the importance of working hard, keeping the economy going strong, and maintaining a healthy supply of food and other goods.” He finishes with a couple of facile comparisons with the 1918 ‘Spanish’ flu epidemic, and the Maji Maji Rebellion in 1905.

Perhaps Magufuli’s critical stance towards Covid-19 would be more constructively contrasted with his far less critical stance towards HIV. 1.6m Tanzanians are living with HIV, 24,000 people died from HIV in 2018 and there were 72,000 new infections.

If the president had said what the WHO and UNAIDS have known for several decades, that crumbling and unsafe healthcare infrastructures are probably responsible for more HIV infections than heterosexual sex, they could have started reversing this trend long ago.

Magufuli went along with other high HIV prevalence countries, took the considerable amounts of money offered, and allowed the epidemic to continue, although incidence has been dropping slowly since the 1990s.

Magufuli is no public health expert, and I don’t think he claims otherwise. But the ongoing response of many countries to Covid-19 is not a viable option, and it’s good to hear that a (very) few countries are saying so. I hope the president does ask for help, given Tanzania’s lack of healthcare capacity and poor health infrastructure.

But Tanzania would be a lot better off turning to Cuba, for example, a country that did a much better job with HIV and healthcare in general in their own country, Ebola in West Africa, and in training people in many other developing countries that lacked trained healthcare professionals (including Tanzania).

There are plenty of issues Taylor could have looked at before wagging yet another neo-imperialist finger at Magufuli, but here’s just one: with an estimated 800 million people affected by hunger every year, globally, and over 9 million people dying of starvation, closing down any of the fragile African economies is not a viable option.

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

Hyperendemic HIV: a WASP factor?


A few weeks ago, I noted that the bulk of HIV infections in sub-Saharan African countries occur in former British colonies, accounting for 72% of people living with HIV and Aids (PLHA). Extending this study to include countries outside of the African continent, the picture is only a little different.

More than two thirds (69%) of PLHA globally live in countries that were either colonized by the British or were heavily influenced by them. India, Brazil, United States, Bahamas, Indonesia and Thailand are the only non-African countries that appear in the top 20, with India and United States being former British colonies.

Similarly, 11 of the top 20 countries for HIV prevalence are former British colonies; the number goes up to 12 if you include Namibia, whose history, politics, administration, infrastructure, etc, have arguably been more shaped by British than by German or South African influences.

Several figures that were not used in the previous post have now been tabulated. Almost two thirds (65%) of annual new HIV infections occur in countries with these overlapping histories. Out of the top 20 countries for new HIV infections per 1000 uninfected people, 12 of them fall into this category.

Although I have not prepared the figures for morbidity by religion, the figures presented show that many of the countries with a predominantly non-Catholic Christian population are also most affected by HIV. In contrast, many of the countries with a predominantly Catholic population (for example, former French, Belgian and Spanish colonies) are less affected by HIV.

Mozambique, alone, stands out as the only one in the top 10 countries by prevalence which was not colonized or strongly influenced by British colonialism. Catholicism is also the biggest religion there, at nearly 30% of the population.

Another figure not included in the previous blog on this subject is for HIV deaths. Just under two thirds of annual deaths (64%) are accounted for by countries previously colonized or heavily influenced by the British.

The table below summarizes the above findings. The top 20 countries account for 81% of new HIV infections, globally, and also 81% of PLHA globally.

The thrust of this site is that HIV epidemics, especially in some sub-Saharan Africa countries, are likely to be driven more by unsafe healthcare and other bloodborne modes of transmission, and less by the ‘unsafe’ sexual behaviour that big HIV institutions would have us believe.

The above data makes no attempt to suggest that there is such thing as ‘WASP-influenced’ sexual behaviour; the received view that 80-90% of HIV transmission is a result of sexual behaviour, but only in the most affected countries, is not founded on evidence.

But the data may show that there is something about certain healthcare infrastructures and/or healthcare administrative structures that explains why the bulk of HIV morbidity and mortality, globally, occurs in countries formerly colonized by the British, or heavily influenced by the British.

The aim of HIV research and analysis should be to prevent further transmission of the virus, not to point the finger at who or what is driving epidemics. But as long as UNAIDS and other HIV focused institutions choose to blame the victims and point the finger at their ‘unsafe’ sexual behaviour, BloodborneHIV.com will continue to search for patterns that emerge from those same institutions’ data.

HIV Risks: Greed and Officialdom


It’s refreshing to experience a work of drama that describes a HIV outbreak which occurs in a healthcare setting, without a hint of the prurience that is so common in most accounts of the subjects of HIV and Aids. The play closes tomorrow in the Hampstead Theatre in London (review).

The King of Hell’s Palace tells the story of Dr Shuping Wang, who risked her life, and the safety of her family and friends, to raise awareness of exceptionally high rates of HIV transmission in Henan Province, China, in the 1990s. These were evidently a result of unsafe practices in plasma donation programs, which were a source of income for hundreds of thousands of people in the province.

Estimates of how many people were infected with HIV and hepatitis C through these programs vary, from 10s of thousands to hundreds of thousands, and it’s impossible to say how many were infected. It’s also likely that many of those infected by the plasma programs went on to infect others, directly and indirectly.

Dr Shuping Wang succeeded in closing down the plasma donation programs. Safety procedures were put in place before they were allowed to restart. An awful lot of damage was done, and those who were benefiting most from the programs were reluctant to see their source of income threatened. But the efforts of one person undoubtedly saved hundreds of thousands of people, perhaps millions.

Most people who watch movies will have seen movies that have been made about HIV and Aids. But the bulk of them are about HIV transmission among men who have sex with men. Some bring in injected drug use, and some include transmission among heterosexuals, especially where sex workers are involved.

However, most HIV positive people in the world are not sex workers, they are not men who have sex with men, they don’t inject drugs and most of them are certainly not white people from wealthy countries.

The majority of HIV positive people live in certain parts of certain sub-Saharan African countries. In other words, they are not distributed evenly among populations, as you might expect of a virus that is, according to the HIV industry, almost always transmitted via ‘unsafe’ sex.

Most people in all countries in the world, African countries included (surveys of sexual and other behaviors), do not engage in the very high levels of ‘unsafe’ sex that would be required to account for massive outbreaks that are found in countries such as South Africa, Botswana, Eswatini (Swaziland) and Lesotho.

Some people in all countries in the world do engage in high levels of ‘unsafe’ sex, but most do not. In fact, even among sex workers in wealthier countries, HIV prevalence is low unless they also have other risks, such as injecting drugs.

What you do find in African countries is unsafe healthcare, badly trained healthcare professionals, quacks and low skilled practitioners who pass themselves off as doctors, nurses and midwives, dispensaries that will give you anything if they can make money out of it, including injections of things you don’t need, and that may do more harm than good.

And yet there has never been a single investigation in sub-Saharan Africa of the kind that closed down the unsafe plasma programs in China in the 90s. There were investigations in Pakistan (still going on), Cambodia, Libya, Russia, Tajikistan and a number of other countries (list of countries which have and have not responded to outbreaks).

The Chinese administration officials in 1990s Henan Province are depicted as greedy, and as being unwilling to risk losing their job and reputation, even though they knew that Dr Suping Wang was right; they were infecting countless people with deadly pathogens just so they could cash in on the demand for plasma.

Similarly, there are officials in UNAIDS and other UN offices, such as the WHO, officials in the CDC, various country administrations in high HIV prevalence countries, academics all over the world and even journalists who see themselves as having a role in highlighting serious injustices; why are they not calling for investigations into outbreaks that affect more than half of young women in some towns in South Africa, Western Kenya, parts of Tanzania, Mozambique and Malawi?

There have been protests and movements demanding rights for men who have sex with men, transsexuals, and others in wealthy countries, where the majority of HIV positive people fall into those groups.

But where the majority of HIV positive people are black, and they are neither men who have sex with men nor injecting drug users (HIV positive females outnumber HIV positive males in high prevalence countries), there are no protests.

About 70% of HIV positive people live in sub-Saharan Africa and over 70% of HIV positive people in the region live in certain towns and cities in just a handful of countries: that’s where the investigations need to be carried out. Surely, no one’s interest is served by continuing to insist that HIV prevalence is high in a few places just because of ‘African’ sexual behaviour?

Can UK Tattoo Artists Guarantee the Safety of their Services?


Apparently some tattoo studios in the UK suggest that they can’t, because they have refused to allow HIV positive people to get tattoos. Legally, they are not allowed to ask their clients to reveal their HIV status. But if they are worried that tattoo artists themselves, or their HIV negative clients, risk being infected if they accept HIV positive clients, they must believe that the precautions they take to avoid transmitting pathogens are not adequate.

The Vice article linked to above mentions the possibility that people who don’t know they are HIV positive may choose to get tattoos or body piercing, which is important. But there are also risks of other serious pathogens, such as hepatitis C, being transmitted. The Vice article concentrates on HIV positive people being discriminated against; but a much more important issue is whether anyone’s safety is guaranteed when they get a tattoo, body piercing or any skin piercing procedure.

Tattoos and body piercing are not the only cosmetic procedures that carry risks of transmitting bloodborne pathogens. It is now possible to get injectable steroids, tanning products, botox and other things that are administered by skin piercing tools, such as syringes, needles, lances and the like. You can order these products online, to be sent to your home, and get them at certain clinics and service providers. So they could be administered by people with little training, or even none at all; people can self-administer them and/or administer them to friends.

Anything that pierces the skin can carry a risk. Sometimes the risk is small, but sharing injecting and other skin piercing equipment can carry a very high risk. Someone else’s blood should never come in contact with yours unless you’re getting a blood transfusion, and your blood should never come in contact with someone else’s.

These incidents outlined by Vice highlight that the complainants have been denied their right to confidentiality, and would be discriminated against for revealing that they are HIV positive. But it also highlights the fact that people providing any cosmetic services that may involve breaking the skin do not all have adequate knowledge about skin piercing and dangerous pathogens. These procedures could even include manicures, pedicures, shaving and hair-styling,

Vice reports one person working at a clinic as saying “Well, if someone has HIV we take extra precautions, especially if they have cuts or broken skin”. But tattooing, piercing, etc, involve cutting/breaking skin, by definition. The very reason they should be taking precautions is because what they do breaks skin!

People providing such services should already ensure that they do not reuse unsterilized instruments, including machinery, paints and anything else that may lead to transmission of a pathogen. No pathogen whatsoever from one client should come in contact with another client, or with the person providing the services.

If service providers do not already take these precautions they should be closed down, and all their clients should be checked for bloodborne pathogens. If they believe they need to, or even believe that can take additional precautions just because their client is HIV positive, they should not be not be providing those services.

HIV: A British Colonial Hangover?


Data Source: UNAIDS

Despite continued claims that the vast majority of cases of HIV transmission in sub-Saharan Africa are a result of heterosexual sex, no clear explanation has been given for the substantial heterogeneity at the national and subnational levels.

In other words, what is so different about sexual behaviour in Morocco, where HIV prevalence is less than 0.1%, and that in Eswatini (Swaziland), where it is 27.2%, 272 times higher?

As an example at the subnational level, what is so different about sexual behaviour in the Kenyan county of Wajir, where prevalence is less than 0.1% and the county of Siaya, where prevalence is 21.0%, over 200 times higher?

Petabytes of data have been collected about sexual behaviour all over the world. Everywhere, some people have a lot of sex, some people have little or none and the rest are somewhere in between. But few useful correlations between heterosexual behaviour and HIV transmission have been found, at national or sub-national levels.

At the national level, the majority of the highest prevalence countries, and the countries with the largest number of people living with HIV are former British colonies. Prevalence ranges from 0.1% (Egypt) to 27.2% (Eswatini), with a median of 6.5% (Uganda).

Data Source: UNAIDS

In contrast, the range in former non-British colonies is 0.1% (Algeria and Tunisia) to 12.4% (Namibia). The median is about 1.5%. A third of these countries have prevalence figures of 1% or below. Less than one third of people living with HIV live in former non-British colonies.

Data Source: UNAIDS

The copious quantities of sexual behavior data referred to above confirm that the British did not introduce a liberal or enlightened attitude towards sex, nor did they promulgate forms of ‘risky’ sexual behaviour not found in French or Belgian colonies. So there must be something unrelated to sex involved, right?

Although modes of HIV transmission have been identified, it seems likely that the contribution of non-sexual transmission via unsafe healthcare and other skin-piercing processes in sub-Saharan African countries has been seriously underestimated by UNAIDS and the other recipients of massive HIV funding.

Currently, people in sub-Saharan Africa receive incessant warnings about sexual risks, with non-sexual risks through unsafe healthcare and other skin-piercing processes dismissed as minor. And although risks of bloodborne infection, especially in healthcare facilities, were identified and addressed in wealthier countries from the 1980s, there have been many outbreaks in poorer countries later shown to be a result of unsafe healthcare.

There are examples of bloodborne HIV outbreaks that have been investigated and confirmed to have been a result of unsafe healthcare. One in Ratodero, Pakistan, is currently being investigated. There was a recent one in Roka Commune in Cambodia that was also investigated. Outbreaks in Romania, China and other countries received international press attention.

However, no bloodborne outbreaks in sub-Saharan Africa have been investigated. Instances that should have been seen as possible bloodborne outbreaks have been ignored. But lurking in the history of healthcare development and practices in Africa, both pre- and post-independence, may be a clue as to why HIV should be so prevalent in former British colonies.

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).