Bloodborne HIV: Don't Get Stuck!

Ebola researchers are still working furiously to gain recognition for ebola as a sexually transmitted infection (STI). The New York Times has been spearheading the media echo chamber’s support for this desperate attempt to blame African people for their illness. ‘Sexually transmitted ebola’ is the culprit, and must be found at all costs.

The reason for the desperation is that, as yet, there is no evidence ebola has ever been transmitted sexually, in the 40 years since the virus has been recognized. Sexually transmitted ebola remains a mere theoretical possibility. Worse than that, a good deal of evidence suggests that the virus is very easily transmitted through unsafe healthcare practices.

Even the media, in it’s great hindsight, has pointed the finger at healthcare as being a weak point in impoverished African countries when it comes to fighting disease, and dealing with massive outbreaks like the one seen last year in several West African countries. But the media are not so good at following that insight to its logical conclusion.

So the ebola campaign seems to be taking a leaf out of the HIV book: UNAIDS, an institution that has been smearing African people for being ‘sexually promiscuous’ for nearly twenty years, is apparently lending a hand. When HIV positive people say they are not promiscuous, as many are not, they are not believed. If evidence for sexually transmitted ebola can not be found, it must be manufactured.

The tradition of wagging accusing fingers at African people about their sexual behavior goes back many decades, long pre-dating the identification of HIV. Eugenicists (often restyled as ‘family planning’ NGOs) and neo-eugenicists have been at it for at least a century.

Even programs to deal with syphilis and other STIs involved a lot of finger wagging and exhortations to address sexual behavior, although many of the big outbreaks had little to do with with sexual behavior and a lot to do with the conditions that people had to live in during colonial occupations.

Thus with ebola, the husband of a woman who died of the virus was asked for a semen sample, as he had recovered from it some time before. He refused and said he had been impotent since recovering from ebola. The doctor leading the investigation said he didn’t believe the man. The doctor is clearly convinced that he has already found a case of sexually transmitted ebola (one out of many thousands) and just needs evidence, however extreme the measures needed to acquire it.

Not believing patients and adopting a ‘veterinary approach’ is part of a pattern in HIV epidemiology. When it is reported that people had ‘no risks’ for HIV, that doesn’t seem to include risks for healthcare transmitted infection. So saying that the man’s wife had no risks for ebola may not exclude healthcare risks, we just don’t know.

The doctor suggested that the man was afraid he would be implicated in his wife’s death, which is not an unreasonable fear, given the way some of the reported ebola programs have been carried out. Many people seem extremely frightened of ‘officials’, and the ‘space suits’ some of them wear is unlikely to be the only cause of that fear. Now, ebola campaigns seem intent on frightening people about sex, by dangling in front of them the fear of sexually transmitted ebola.

But the story just gets more bizarre. A female UNAIDS ‘counselor’, said to be an expert in human (allegedly) sexuality, was employed to ‘talk’ to the man before he tried, unsuccessfully, to produce the semen sample. The man said that two other men, whom he assumed to be doctors, joined the UNAIDS ‘counselor’ and “tried to manually stimulate him with soap while pornographic videos played on a laptop”.

The history of UNAIDS and the HIV industry’s attempts to stigmatize Africans by insisting that heterosexual sex accounts for almost all HIV transmission in African countries (but not elsewhere) makes that obscene scenario seem quite believable. The doctor leading the investigation claims none of it happened, he just supplied the video and laptop, but working with UNAIDS will not improve his credibility.

The similarities between ebola and HIV programs continue with the steadfast refusal to consider the possibility that unsafe healthcare resulted in both the ebola and HIV epidemics. Why is it not possible to investigate the role of unsafe healthcare and deal with it? There are shortages of equipment, supplies, personnel, skills and the like, vital to ensure good and safe practices: healthcare transmitted ebola and HIV can not be ruled out.

Unsafe healthcare has resulted in massive outbreaks of hepatitis, particularly hepatitis C in Egypt, of tuberculosis (TB), particularly drug resistant TB in South Africa and neighbouring countries, and of ebola in all the outbreaks before the recent ones in West Africa, such as those in the Democratic Republic of the Congo and Sudan.

If healthcare transmitted ebola, HIV, TB, hepatitis and other diseases remain unacknowledged and unaddressed, massive outbreaks like those seen in many African countries will continue. The search for ‘sexually transmitted ebola’, like the search for ‘sexually transmitted HIV’, will deflect attention from the very real, and very deadly problem of unsafe healthcare in Africa.

Victims of the Guatemala Syphilis Experiment (1945-1956) failed in their attempt to sue the US Government for actions that a presidential bioethics investigation admitted “involved unconscionable basic violations of ethics” in 2010; the judge declared that “the US government cannot be held liable for actions outside the US”.

So the victims have now launched a lawsuit against the Johns Hopkins University over its involvement, something the university has ‘vigorously denied’. The university has expressed ‘profound sympathy’, which I’m sure the victims and their families will appreciate.

These vigorous denials were echoed by the Rockefeller Foundation, who also claim to have had nothing to do with the experiments. Big Pharma giant Bristol-Myers Squibb declined to comment.

This infamous episode in the history of American public health experimentation overlapped with the much longer and more extensive Tuskegee Syphilis Experiment (1932-1972). Although this occurred within the US, the victims were African-Americans, so the vigorous denials and profound sympathies were not deemed necessary until some time after the experiments had been halted.

Carrying out questionable public health programs in non-US countries by US institutions is a lot more common now. Injectible Depo Provera hormonal contraceptive (DMPA) is rarely used among non-white or wealthy populations, inside or outside the US. This is despite the fact that the drug has been shown to double the rate of transmission of HIV from HIV positive men to HIV negative women, and from HIV positive women to HIV negative men.

The vigorous denials continue: just search for #DMPA on Twitter and the same faces come up over and over. The tweeters often attack anyone questioning the use of DMPA, especially among poorer non-white women in the US and among people in African and Asian countries, where it is often the most common form of birth control used.

Those defending DMPA don’t generally deny that it doubles HIV risk, as they are often among the research teams who estimated this risk in the first place. They tend to argue that a doubling of risk is not high enough to warrant issuing proper warnings, and that the risk of being infected with HIV is not as serious as the risk that those using DMPA may have an unplanned pregnancy, as if there are no other contraceptives available!

Spite towards Africans expressed through dangerous ‘public health’ programs was entirely normalized once it was decided, for purely political reasons, that HIV should be marketed as a sexually transmitted infection that heterosexuals were very likely to contract and transmit.

Although the virus mainly infects men who have sex with men (MSM) and intravenous drug users (IDU) in wealthy and middle income countries, it mainly infects people who are neither MSM nor IDUs in Africa. In fact, the largest demographic infected in most African countries is women from their mid teens up to their late forties.

How could this be so?

Well, if you’ve ever had the misfortune of being treated in an African hospital, given birth there, or even just visited someone you know, you will find it very easy to believe that unsafe healthcare constitutes a huge, but under-researched risk. Less of a risk, but also under-researched, are unsafe cosmetic and traditional practices.

Consider this when reading about some of the experiments carried out in Guatemala: “Prostitutes were infected with venereal disease and then provided for sex to subjects for intentional transmission of the disease”, syphilis was injected into the spinal fluid of some victims.

Children were also subjected to these ‘experiments’, as were orphans, prisoners and mental health patients. Some of those involved were worried about what people not involved might think if they found out, but they don’t seem to have worried about their victims; one woman is reported to have had gonnorheal pus from a male subject injected into both her eyes.

But it’s not only African (or African American) women that are so maligned by wealthy western institutions that massive ‘public health’ experiments can be carried out using public money, often resulting in private gain, with total impunity. The English Guardian article notes two ‘experiments’ carried out on men, aiming to infect them with sexually transmitted infections and then watching the effect this had on them, their families and others around them.

For example, “An emulsion containing syphilis or gonorrhoea was spread under the foreskin of the penis in male subjects” and “The penis of male subjects was scraped and scarified and then coated with the emulsion containing syphilis or gonorrhea”.

This obsession with sex, sexuality and sexual organs continues to occupy publicly (and privately) funded western HIV scientists in African countries. Research into non-sexual transmission of HIV is almost unheard of, except in the form of ‘vigorous denial’ that it ever occurs.

The enormous Mass Male Circumcision programs (MMC), which have attracted several billion dollars, are targeting tens of millions of Africans. And yet they are predicated on the view that HIV is almost always transmitted through heterosexual sex, a view that is entirely based on the prejudice of ‘experts’. (There are over 100 posts about mass male circumcision on this blog).

These circumcision programs are targeted, like Tuskegee, Guatemala and the use of Depo Provera, at non-white, poorer people, often African and female (while the MMC programs must target men, the operation has been shown to double transmission from males to females).

Data collected is often published selectively, to promote funded interests, and anything that suggests the programs are harmful is either uncollected, ignored or remains unpublished. Those criticizing such practices are attacked, branded, ridiculed and persecuted by professional (and often very well qualified) trolls.

In years to come, articles in the English Guardian may describe these appalling practices, that occurred in the past, as if they could never happen in the present. But similar phenomena continue to occur, with funding from western governments, ‘philanthropists’, academic institutions and others, while the public (and the media) look the other way.

The English Guardian has an article on the decision of a Kenyan court to amend a law that criminalizes certain instances of HIV transmission, potentially including transmission from mother to child. But the author misses the true injustice of the law, which is one of many instances of woman bashing and victim blaming that the HIV industry and the media have made their staple fare.

The true injustice is that many women in African countries are infected with HIV through non-sexual routes, probably through unsafe healthcare, but also possibly through unsafe cosmetic and traditional practices that involve skin piercing. These infections are avoidable: women need to be told that they face such risks, that HIV is not just a sexually transmitted virus, that it is not even predominantly sexually transmitted.

As long as the media continues to spew out the misogynistic rubbish they receive from UNAIDS and the HIV industry’s PR machinery about HIV almost always being transmitted through unsafe heterosexual sex in African countries (but not elsewhere), countries like Kenya will pass unjust laws like this one.

The media also loves rubbish about ‘deliberate’ transmission of HIV, ‘revenge’ transmission, anything extreme, which they depict as normal for Africa. The level of anti-African bigotry to be found in the media is on a par with the kinds of antisemitism that was commonplace in many countries before the second world war.

Of course, extreme levels of misogyny are reserved for African women. In the US, a woman has received a 20 year prison sentence for having an abortion. So state sponsored violence against women doesn’t even raise an eyebrow in the US either? But the difference is that the English Guardian recognizes the injustice in this case, but not in cases of HIV in women in African countries.

Prevention of mother to child transmission of HIV (PMTCT) is a wonderful technology, and has probably saved many lives and averted numerous infections. But what about averting infections in the women first? This would be the best strategy for averting infections in infants.

It is of vital importance for women to know what HIV risks they face, so that they can take measures to protect themselves. The Guardian’s humbug conclusion that “The law also puts women at risk of violence or rejection by their husbands because it allows doctors to disclose the status of patients to their next of kin” needs to be rewritten.

It is the HIV industry and institutions like UNAIDS that insist that women’s biggest risk for infection with the virus, even their only risk, is unsafe sex. Many African women have just one sexual partner, and that person is HIV negative. Many HIV positive women were infected late in their pregnancy, even just after giving birth.

It is unpardonable to insist that all HIV positive mothers must have had sexual intercourse with someone other than their partner. This is what puts the women at risk of stigmatization, violence and rejection, as well as at risk of being infected with HIV, and infecting their fetus or infant.

This kind of victim blaming is a clear instance of violence against women, yet it is promulgated by the very parties who claim to be protecting the rights of women: UNAIDS, WHO, various academic instutions and the enormous, top-heavy HIV industry that they and others constitute. And the media tag along, like poodles doing tricks for the odd pat on the head.

The quote “If we want to reduce the spread of HIV and Aids and put an end to the stigma, violence and discrimination surrounding the disease, our public policies must be based on medical evidence and grounded in human rights” would be spot on if it added that the view that HIV is almost always transmitted through heterosexual sex in African countries is most certainly not based on medical evidence, or any other kind of evidence.

I can’t answer the question in the title, and I don’t want an answer. What I want is that healthcare pros stop sliming suffering people with unsupported suspicions and accusations.

In a recent example of this reprehensible behavior, a senior member of Liberia’s Ebola Case Management Team speculated that a Liberian woman identified with Ebola in mid-March – several weeks after the last previous Liberian tested positive for Ebola – might have “had sex with a survivor” (http://abcnews.go.com/Health/wireStory/liberia-investigates-latest-ebola-patient-infected-29805278).

The infected woman has 5 children and a modest job – selling food in the market (http://www.gnnliberia.com/articles/2015/03/22/liberia-int%E2%80%99l-partners-visit-latest-ebola-victims%E2%80%99-home). Having Ebola is a heavy burden for the woman and her family and a threat to her neighbors. For her to be slimed in public – by a government official speculating about her sexual behavior – can only add to their sorrow and confusion.

What is the most likely source of her infection? Based on more than 20 Ebola outbreaks from 1976 to 2015, if the woman has not been caring for someone with Ebola (she hasn’t), she most likely got it from attending a healthcare facility that reused instruments without sterilization. Hundreds of cases of Ebola have been documented from unsafe healthcare, while no – none, nada, zero – cases of Ebola have been traced to sex with a survivor.

Is Liberia’s Ebola Case Management Team considering the possibility the woman got Ebola from a healthcare facility? Very likely, yes. Whereas the Ebola outbreak continues in Sierra Leone and Guinea, Liberia’s outbreak is over or nearly so. Such success is evidence that Liberia’s Ebola Team is competent – that it has recognized and addressed patients’ risks to get Ebola in hospitals and clinics.

Competent, yes, and that’s important. But the Team has been and continues to be unethical in not acknowledging such risks to the public.

A similar assessment applies to experts dealing with HIV in Africa. Consider, for example, that roughly 50% of married HIV-positive women in Africa – over 80% in the Democratic Republic of Congo and Sierra Leone – have HIV-negative husbands (data from Demographic and Health Surveys available at: http://dhsprogram.com/What-We-Do/survey-search.cfm?pgtype=main&SrvyTp=country).

Healthcare pros’ repeated assertions that sex is the source of almost all HIV infections in Africa charge all such women with extramarital sex, a charge that is a slur in many cultures. Such sliming is a de facto policy. Virtually all organizations that bankroll HIV prevention in Africa — UNAIDS, WHO, USAID, Gates, and others – require people they fund to aver that almost all HIV infections in Africa come from sex.

Many healthcare pros knowledgeable about HIV are aware of such nonsense. Those who speak out – who are both competent and ethical – have no chance to work on HIV in Africa. They are pushed aside in favor of others who are either ignorant or unethical (or both).

A recent study asks ‘Does HPV [Human Papilloma Virus] Vaccination Promote Unsafe Sex in Adolescent Females?‘ and the answer is a resounding ‘no’.

Those who followed similar questions about condom promotion ‘promoting’ unsafe sex, comprehensive sex education ‘promoting’ unsafe sex, and the like, will be unsurprised, because all of these interventions have had positive impacts, and all have been shown not to result in increases in unsafe sex.

On the other hand, the $1.3 billion that PEPFAR, the (US) President’s Emergency Plan for AIDS Relief, spent on abstinence and faithfulness programs “showed no evidence the messages had any impact on behavior or HIV risks“.

I wonder how many billions of non-PEPFAR money went into similarly ineffective programs, and how much is still being spent on programs either destined to fail, or destined to do more harm than good, such as the massive male circumcision programs currently underway.

One piece of research found that “[T]here was no evidence of a reduction of [HIV] incidence in women as a consequence of the reduction in HIV prevalence in men due to circumcision“. And that’s after nearly seven years of circumcising people and assuring them that incidence among women will also drop.

They now say it could take ten years to see any impact on women, something I don’t remember hearing when the programs were being aggressively promoted. So we should see results in three years time in Rakai, then? Of course, it will be difficult to tell which were the effective programs in a place where so many HIV activities are taking place at the same time.

The only evidence about the effect of mass male circumcision on male to female transmission of HIV is that it increases it by 50%, yet women are a lot more likely to be infected than men already, and this is being aggressively marketed to women as well as men.

HPV is vaccine preventable, yet in the US an estimated 25% of females between age 14-19 are infected. HPV causes cancer and genital warts. But “vaccination rates are low, partly because of a perception that vaccination may promote unsafe sexual activity among recipients.”

This irrational fear of ‘unsafe sex’ appears to increase the risk of HPV and its consequences, also the risk of HIV, unplanned pregnancy and various other avoidable conditions. Advances in public health appear to evoke the most extraordinary reactions in some people.

On 23 February, WHO announced its intention to promote auto-disable syringes for curative injections[1]. This is a hugely encouraging response to an HIV outbreak discovered in Roka village, Cambodia, in December 2014 – hundreds of villagers infected through unsafe healthcare.

Unfortunately, WHO’s press release announcing its commitment to promote auto-disable syringes low-balled the risk to get HIV from unsafe health care. The press release cited a recent WHO-sponsored study[2] that estimated unsafe medical injections accounted for less than 1.3% of HIV transmissions in the world in 2010. The authors of that WHO-sponsored study calculated their estimates using a model that depends crucially on an assumed low rate of HIV transmission through contaminated syringes and needles. The authors assumed that if a doctor or nurse injects someone with HIV and then reuses the same syringe and needle – without boiling them – to give you an injection, your risk to get HIV is only 0.32%-0.64%. To support such an assumed low risk, the authors cited similar assumptions from other papers and authors – all of which ignored and/or rejected evidence of transmission during actual outbreaks where medical injections transmitted HIV.

The outbreak in Roka, Cambodia, gives us a chance to test these low-ball assumptions. If the risk to transmit HIV from an HIV-infected patient to a later patient through reused, unsterilized syringes and needles was 0.32%-0.64% only, someone infected with HIV would have to have, on average, 156 (=1/0.0064) to 313 (=1/0.0032) injections after which equipment was reused without sterilization to infect one other person. If the average person living with HIV got 15 injections per year (an absurdly large figure) it would take an average of 10 to 20 years for him or her to transmit HIV to one other person through unsafe injections. People living with HIV would, on average, die before infecting someone through an unsafe injection.

In short, with the transmission efficiencies Pepin and colleagues assumed (in the study cited by WHO’s press release), the outbreak in Roka, Cambodia, was impossible.

For decades, health care authorities who could stop transmission of HIV in health care have chosen not to do so. They have chosen to stick their heads in the sand, to accept ridiculously low assumptions about HIV transmission efficiencies through contaminated instruments, not to warn patients at risk, to give deceitful assurances, etc.

WHO’s endorsement of auto-disable syringes is a step in the right direction. Much more is required to change the trajectory of largely unnecessary and easily preventable HIV epidemics in Africa – eg, outbreak investigations, acknowledging common risks in formal as well as informal health care settings, etc.

1. WHO. WHO calls for worldwide use of “smart” syringes. Press release 23 February 2015. Available at: http://www.who.int/mediacentre/news/releases/2015/injection-safety/en/ (accessed 24 February 2015).

2. Pepin J, Abou Chakra CN, Pepin E, Nault V, Valiquette L (2014) Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010. PLoS ONE 9(6): e99677. doi:10.1371/journal.pone.0099677. Available at: http://www.plosone.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pone.0099677&representation=PDF (accessed 24 February 2015).

The comments following an article about hepatitis C (HCV) appearing in the English Guardian suggest that some people still associate the virus with illicit drug taking, illicit sexual practices and those who engage in such activities. Sadly, the article doesn’t make much effort to dispel such views.

Several of the people commenting who have been infected with HCV sound as if they don’t quite understand how this came about, although they know that they have never engaged in any of the well publicized activities that are said to constitute the most serious and the most common risks.

We shouldn’t be facing this problem with HCV; it’s much too like the problem we still face with HIV, the view that it mainly infects people who engage in illicit activities of some kind, their partners and even, sometimes, their children. Trying to scare people about heterosexual HIV being the tip of an iceberg, when public health authorities knew perfectly that that wasn’t true, backfired.

It will backfire with HCV too. Many people are still afraid to be tested for HIV, to be frank about their status, to discuss it with people with whom they may become sexually involved, etc. So why are we risking the same sort of stigmatization with HCV?

The article says: “Only in recent years have doctors realised that the hepatitis C virus (HCV) can be sexually transmitted. As it is carried in the blood but not present in significant amounts in semen and other bodily fluids, the risk of transmission during sex was presumed to be negligible. That was until patients who had never injected drugs started testing positive.”

But patients who had never injected drugs, nor had any other identifiable risks, may have had an endoscopy, colonic irrigation, treatment with contaminated vials (generally multi-dose vials), been exposed to insulin pens, fingerprick lances, been circumcised in a non-sterile setting, received certain beauty treatments (eg, blackhead removal), complementary therapies, or skin-piercing and other invasive traditional practices, shared certain types of haircutting equipment, including machinery, donated blood (donors can face a risk from reused equipment), served time in prison, had anything inserted into a mucus membrane (including hands wearing reused surgical gloves), etc.

The article mentions sharing toothbrushes and razors as if that’s the end of it. The research that the article refers to makes it clear that the relative contributions of various risk factors, whether sexual or non-sexual, have not yet been established.

Mentioning that “Rougher sex, anal sex and the sharing of sex toys, especially among people who are also infected with HIV, make sexual transmission possible” may spice up the article a bit, but it could also deflect attention from other risks. These other risks may well be a lot less likely to transmit HCV (or HIV) than certain sexual practices or intervenous drug use, but the list includes things that many people do many times a year.

We need accurate and comprehensive information about hepatitis C, not scare tactics resembling the ones that failed so devastatingly with HIV. In addition to common skin-piercing and invasive healthcare, cosmetic and traditional practices, it is possible that ordinary, everyday sex, transmits HIV; it may not be as risky as the spicy kinds journalists like to report on, but it is likely to be a damn sight more common.

The news that the World Health Organization (WHO) is calling for exclusive use of auto-disable syringes, which are designed to break if reused, is probably the most significant advance in the reduction of HIV transmission in developing countries to be announced in many years. It should also reduce transmission of other blood-borne viruses, such as hepatitis B and C, also ebola and MERS.

The WHO has started their global campaign to increase awareness of the dangers of unsafe healthcare, especially through reused syringes, needles and other skin piercing equipment, and have issued a brochure on injection safety.

It’s lucky that the inventor of the K1 auto-disable syringe, Marc Koska, heard about the problem of reused injecting equipment in 1984. Only a few years later attention was drawn away from unsafe healthcare to unsafe sexual behavior as the main route of transmission for HIV.

Although HIV in wealthy countries now mainly infects men who have sex with men and people who inject illicit drugs, and this was already clear in the late 1980s, public health institutions decided to emphasize the risks people face from heterosexual sex.

Perhaps these institutions had their reasons, and the campaign was ‘successful’; many people all around the world still believe that heterosexual sex is the biggest risk for HIV. The risk to heterosexuals was, and is, very low, but few people around in the 1980s could forget the relentless scare campaigns.

But in poorer countries, most people becoming infected with HIV were clearly not men who had sex with men or injecting drug users. They were just ordinary people, many of whom who had never had sex, never had ‘unsafe’ sex, or only had sex with a person who was also HIV negative.

There were also a lot of infants infected by their mothers, and there still are, although the prevention of mother to child programs have been among the most successful in the history of HIV.

The issue of non-sexual transmission of HIV in developing countries remained ignored, even strenuously opposed by what became an enormous HIV industry. And so, those infected with the virus, and whose infants were infected with the virus, were accused of being promiscuous, careless, dishonest and even cruel to their family and those around them.

Perhaps this will herald in a new era, making it possible to raise the issue of non-sexual transmission of HIV through unsafe healthcare without accusations of denialism (although it seems to be the opposite of denial), being anti-scientific (although there is no shortage of evidence) or of diverting attention from the importance of sexual behavior, which was never as important as the massive scare campaigns would have us believe.

One newspaper article cites Koska as saying “I always wanted to be a superhero and save the world”. I don’t know if he really said that, but I’d like to believe he did. Because the benevolence of his motives contrast strongly with the apparent motives of certain parties in the burgeoning HIV industry, for whom HIV transmission is but a route to wealth, power and career advancement.

There’s a very succinct set of photographs by Marc Koska of the SafePoint Trust about the HIV outbreak in Cambodia’s Roka Commune. Over 270 people are said to have tested positive so far, several of whom have already died. Unsafe healthcare is thought to have been behind this outbreak, reuse of syringes and other skin piercing equipment by medical practitioners who do not have the knowledge, skills or equipment to avoid such occurrences.

Koska invented an auto-disable syringe many years ago, a syringe that breaks if you try to reuse it, but he has been lobbying health and HIV institutions to promote the use of this simple and cheap technology ever since.

It is highly unusual for the BBC to express the slightest hint of disagreement with the mainstream view of UNAIDS and other institutions, that HIV is almost always transmitted through unsafe sex, and hardly ever through unsafe healthcare. Perhaps because this outbreak was in Cambodia, where HIV prevalence is low, this story flew under the radar.

Sadly, as the article points out, use of auto-disable syringes is too late for those already infected, but it is not too late for other Cambodians, nor for HIV negative people living in countries where HIV and other blood-borne viruses are common and, more importantly, where safe healthcare is uncommon.

UNAIDS and others in the HIV industry have been ranting on about ‘unsafe sex’ and completely avoiding the issue of unsafe healthcare, even denying its possible role in the most serious HIV epidemics in the world, which are all in Africa. Perhaps this will bring various kinds of unsafe healthcare into focus, however belatedly.

Cambodia is not the only Asian country where unlicensed practitioners operate; and even licensed practitioners may reuse needles, syringes and other skin-piercing equipment. The practitioner who has so far been the only scapegoat is unlikely to be the only person to practice healthcare unsafely. The investigation should be global, not confined to a population of a few thousand.

As for African countries, it should be clearer than ever that unsafe healthcare must no longer be denied by UNAIDS and other health agencies as an important mode of transmission of HIV and other viruses in African countries. People shouldn’t have to be Buddhist monks, very young or very old to be believed when they say they have not engaged in ‘unsafe’ sex, or any sex at all.

The UNAIDS view that HIV is almost always transmitted through ‘unsafe’ sex and hardly ever through unsafe healthcare is vehemently expressed in a BBC article from 2003, and these views don’t appear to have changed since (although the UNAIDS official in question, along with some of her senior colleagues have since availed themselves of the revolving door).

The maliciously racist view of Africans that the senior UNAIDS official is, apparently, allowed to make public, doesn’t seem to have changed either.

It’s also worth bearing in mind that UNAIDS are well aware of the risks of healthcare transmitted HIV and other infections in developing countries. They publish a brochure warning UN employees not to use health facilities in such countries; this contrasts very strongly with what the BBC published the year before. Perhaps now they UNAIDS will promote this in Cambodia, and hopefully in Africa too?

Following my previous post, I’ve put together some of the data available on HIV and circumcision on this site, along with some additional data, in order to emphasize a few points.

Convincing arguments have been made to show that there is no overall benefit found when comparing HIV prevalence among circumcised and intact men in a number of countries for which figures are available; prevalence is higher among circumcised people in some instances and higher among intact people in others.

This raises the question of whether circumcision, or perhaps circumcision on its own, might be irrelevant to heterogeneity among HIV epidemics. After all, there are other differences, aside from circumcision status, between the populations of various countries for which figures are available.

Here’s an example: there’s a group of seven countries which were formerly colonized by Belgians, French and Portuguese (or remained uncolonized) for which circumcision/HIV related information is available. With the exception of Mozambique, the former Portuguese colony, HIV prevalence in the others is low to medium. The total number of HIV positive people in these countries is estimated at just under four million.

But there’s another group of nine countries which were formerly colonized by the British. Although prevalence is low in one of them, located in lower prevalence West Africa, the others are all high to very high prevalence countries, coming to a total of just over nine million HIV positive people. Indeed, about 80% of all HIV positive Africans reside in former British colonies, which comprise more than half the population of Africa.

Undeniably, HIV prevalence and circumcision do show a very strong North/South divide. Most men (and many women) in northern African countries practice some form of genital alteration, known as circumcision when applied to men, and HIV prevalence is very low in these countries. In contrast, circumcision is not predominant in most of the highest prevalence countries in southern Africa.

There are fewer than 150,000 HIV positive people in Egypt, Libya, Algeria, Niger, Mauritania, Tunisia, and Morocco combined, these countries comprising almost 20% of the population of Africa. But I would argue that the northern countries did not ‘successfully fight off’ HIV, as is sometimes suggested. In fact, the virus didn’t arrive in the region until the mid-80s, more than three decades after it established itself in eastern Africa.

There are sex workers, men who have sex with men, intravenous drug users, clients and partners of these groups in northern African countries, just as there are in all other countries in Africa (and the rest of the world). The enormous Sahara Desert may have shielded northern African countries to some extent from the spreading virus, but prevalence is not low there because ‘unsafe’ sex is less common than in southern countries.

Southern and eastern African countries are almost all former British colonies, whereas only a handful of former British colonies can be found in Equatorial, western or northern Africa. Of course, the British colonials didn’t spread a virus they still hadn’t heard of, nor did the non-British colonials avoid spreading it.

Rather, the colonials developed the structures that allowed the virus to spread, with varying levels of efficiency; the roads, railways and ports, the overcrowded cities, the oversubscribed health facilities, the industrial outlets, especially extractive industries, the huge pools of labor, living in squalor away from their families, etc.

So, the influence of certain types of administration on determinants of health (and disease) may be behind much of the heterogeneity found HIV epidemics in African countries. But there is nothing to lead one to the conclusion that circumcision status, or even sexual behaviour, are clearly linked to HIV prevalence.

If you start out believing that HIV is almost entirely transmitted through ‘unsafe’ sexual behavior, and that circumcision gives some level of ‘protection’ against HIV transmission, some of the figures bandied about might persuade you that it’s a good idea to spend billions aggressively recruiting as many men as possible to be circumcised; but that’s all down to your preconceived views.