Bloodborne HIV: Don't Get Stuck!

Professor Robert van Howe was requested, in his capacity as a pediatrician with an expertise in male circumcision, to peer-review the US Centers for Disease Control and Prevention’s (CDC) draft recommendations following their ‘Consultation on Public Health Issues Regarding Male Circumcision in the United States for the Prevention of HIV Infection and Other Health Consequences’. The full peer-review is available on the Academia.edu site, with some comments and a brief extract on the Circumcision Information website.

One might think, from the constant bombardment of articles in praise of circumcision, that there was a fair body of thought in favor, and a comparable body of thought against the practice. However, the majority of countries in the world do not practice routine male circumcision for ‘medical’ purposes, and only a minority do so for religious and/or cultural reasons. Enthusiasm for the operation for ‘medical’ reasons emanates almost entirely from the US.

Van Howe’s critique is not technically difficult, and many of the arguments against male circumcision would be widely accepted, perhaps even by those who have little familiarity with the subject. But the list of criticizms of the CDC’s draft runs to over 100 pages, with the bibliography of literature supporting the case against the operation running into another 100 pages.

The CDC draft is found to lack scientific and scholarly rigor, neglecting important and relevant findings, but using reviews and other lower quality material instead. Research was carried out carelessly and reported badly. Grasp of basic epidemiology among those who wrote the draft is also low. Van Howe suggests that these apparent flaws may have been part of a deliberate attempt to bias the subsequent recommendations.

In addition to highly selective analysis of medical evidence, ignoring any that might not support what seem like CDC’s prior belief in the virtues of male circumcision, the authors continue a long tradition among proponents of the operation of failing to discuss any kind of causal mechanism by which it might ‘prevent’ HIV or various sexually transmitted infections (STI).

While US professional medical associations resolutely stand by their long held regard for circumcision, equivalent associations elsewhere continue to express their opposition to it. The CDC’s draft neglects to mention any of this substantial opposition by experts. Yet the intention of the CDC’s recommendations are that they will form the basis of advice and information to be given by medical professionals to members of the public about the operation.

Van Howe’s recommendation is that this draft be scrapped and the process be started again, from scratch. He also advises that they ” review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa.”

But what’s this about Africa? Van Howe finds that much of the ‘evidence’ for the claimed benefits of circumcision in ‘reducing’ transmission of HIV and other STIs comes from studies carried out in African countries, despite being used to support their arguments that it should be routine in the US. These often-cited studies carried out in Africa are themselves highly questionable, were carried out by people who were already convinced that circumcision ‘reduced’ HIV transmission, and have spent many years (and many millions of research dollars) trying to push their agenda in African countries (with varying levels of success).

The US is by no means the lowest HIV prevalence country in the world. In fact, it has the highest prevalence among wealthy countries, despite spending a lot more per head on health than some others. The largest HIV positive population in the western world can be found in the US, even though there are probably more men there who were circumcised for ‘medical’ reasons than in any other country.

Van Howe’s article may come closer to listing every major argument against male circumcision as a ‘medical’ intervention against HIV and STIs than any other; it certainly provides counter-arguments against the sort that the CDC draft seems to be filled, flimsy, half baked maunderings and puerile innuendo, apparently the best that many years of study by a whole team of researchers can muster. Even if you can’t read the entire peer-review it will be a good source of information, with a very comprehensive bibliography.

The CDC must be a very powerful part of American democracy if they can spend so much effort and money lying to the public about male circumcision. The operation has been entirely discredited as an intervention for reducing HIV and STI transmission, even in African countries that have far more serious HIV epidemics than the one in the US. But it’s difficult to imagine why this lie is supported by so many US professionals, academics, institutions and money.

The failure of the VOICE pre-exposure prophylaxis trial, daily treatment of HIV negative people with antiretroviral drugs via a vaginal gel, was guaranteed by the long and widely held assumption that almost all HIV transmission in African countries is a result of ‘unsafe’ sexual behavior.

Participants were deemed to be at risk of being infected with HIV by researchers who had no evidence for this risk. In fact, sexual risk was low, with only one fifth reporting more than one sex partner in the previous three months, low rates of sexual intercourse, very high rates of condom use and fairly low rates of anal sex (which may or may not have involved condoms).

During this trial HIV incidence was very high, 5.7 cases per 100 person years, although it went as high as 9.9 per 100 person years in Durban, a figure that is in urgent need of investigation. Yet, researchers made no effort to find out how the several hundred seroconverting women were infected. There were high rates of certain sexually transmitted infections (though low rates of others); could some women have been infected with HIV as a result of unsafe treatment at an STI clinic?

A whopping 71% of the participants use injectible Depo-provera (DMPA), which is known to significantly increase HIV transmission risk from women to men and from men to women. Two thirds of participants were from Durban, in South Africa’s highest prevalence province, Kwa-Zulu Natal. To what extent could this have contributed to these high HIV transmission levels?

It is to be wondered if taking part in this trial could have exposed many women to the risk of being infected with HIV, given that they were selected on the basis that they were currently uninfected and had low sexual risk at baseline.

Whatever the answer to these questions, the unwarranted but ubiquitous assumption that HIV is almost always transmitted through heterosexual intercourse in African countries (but not elsewhere) remains in urgent need of revision. But where does it come from?

UNAIDS, effectively a UN funded lobby for the rich and powerful pharmaceutical industry, bandies the figure about at every opportunity. The claim had been made before this lobby was spawned, but it seems impossible now to identify any body of evidence to support it. Indeed, evidence claimed to support it often suggests the opposite, such as the baseline figures collected by the VOICE study.

Until the HIV industry establish how people are being infected with HIV and employ appropriate (and effective) prevention interventions, high rates of transmission will not stop in African countries. The continued recruitment of vulnerable people in high HIV prevalence areas for trials adminsitrated by researchers who are so entirely blinded by bigotry is inexcusable.

To make matters worse, some are calling for types of monitoring that no longer require them to rely on answers given by participants themselves. This is yet another instance of a ‘veterinarian’ approach to Africans, similar to the insistence on the utility of injectable Depo-provera (DMPA) in developing countries, despite evidence of harm that even those promoting the drug do not deny.

There is a supremely patronizing article on the trial in the New York Times which, like the researchers, can’t accept the possibility that it failed for any other reason than the “elaborate deceptions employed by the women in it”. Nothing is said about the elaborate deception of the HIV industry and the researchers eagerly looking for any way of giving pharmaceutical companies the green light to sell ever growing quantities of their grossly overpriced products.

Instead of admitting to any of their obvious failures, researchers are finding ways to get around trial conditions specifically designed to ensure that such trials do not depend entirely on lies and subterfuge in their efforts to find positive results for the various sub-sectors of the HIV industry that stand to benefit most.

Viewed from a different angle, the many rumors that the NY Times article refers to are not surprising, given the experiences of African people countries of unethical practices, harmful procedures, fudged figures for adverse events (or a failure to report them), outright lies told to participants and cover-ups of evident harm to people taking part in trials, and even to people taking various medications.

The issue of payments to participants is briefly discussed (after all, if there’s sex there must also be money, right?). One ‘global health specialist’ says “I’ve never been concerned that money is the factor driving participation or is corrupting the results”. He may like to revise that view during future trials, rather than by further eroding the already weak protection from abuse that participants currently receive.

When a trial fails as miserably as the VOICE trial, researchers need to re-examine some of their most unsupported assumptions, particularly their most bigoted ones. Then they might think twice (or even once) before accusing participants of deception, in addition to promiscuity, lack of understanding, and indifference to the risk of transmitting a deadly disease to their partner and their children.

What probably should have remained someone’s blog post about a visit to Western Kenya has been published in the Journal of Public Health. A young woman was taken to a ‘disco funeral’ in Western Kenya and was told about what happens during such events. The woman goes on to speculate about sexual behavior at funerals, HIV, and possible connections between the two.

However, the article reads like an uncritical and unreflective account of the experience of one white woman being invited to a funeral and attracting the interest of a drunken man while there, and does not seem to shed any light on the possible contribution of ‘disco funerals’ to HIV transmission, which is probably very small indeed.

The author appears to have believed everything she was told, and even found other published articles to support some of her claims. However, any kind of direct connection with HIV transmission seems tenuous for several reasons:

First, it is claimed that the Luhya of Western province and the Luo of Nyanza province engage in ‘disco funerals’. Yet HIV prevalence is several times higher among the Luo than it is among the Luhya.

Second, these practices, as the author goes to some length to explain, take place in remote areas. Yet HIV prevalence is generally much lower in remote areas than it is in towns and cities.

Third, the entire account is anecdotal, it has no academic merit whatsoever.

Agreed, HIV is sometimes transmitted through unprotected sex, but not always. Evidence of ‘unsafe’ sexual behavior is not evidence of HIV transmission. Also, evidence of HIV transmission is not evidence of unsafe sexual behavior. The author of the article seems to have accepted both fallacies.

Clearly, there are social problems in these provinces, such as alcoholism, drug abuse, sexual abuse and the like, just as there are everywhere. But what is described in the articles and labelled as a ‘cultural practice’ sound very much like a funeral (albeit different from what the author may have experienced in Harvard, or anywhere else in the US).

The fact that some people drink too much and engage in various forms of behavior that can carry all kinds of risk, including sexual risk, does not make the events much different from parties, weddings and other get-togethers, that take place in many countries aside from Kenya, perhaps even in the US.

The term ‘disco funeral’ sounds very much like something made up by a journalist, perhaps similar to the one who wrote an article about this subject in IRIN, a publication that prefers a more sensationalist angle when addressing these ‘issues’. But it seems unlikely that identifying social problems associated to a greater or lesser extent with funerals is the key to high HIV prevalence among some tribes in some places and low prevalence among other tribes in other places.

Various sources, apparently including academic journals, seem to publish just about anything about African countries, as long as it contains magic words like ‘culture’ and ‘tradition’, and florid descriptions of commonplace practices. But even identifying sexual practices that could be referred to as an aspect of ‘culture’ or ‘tradition’ does not necessarily tell us anything about how HIV is being transmitted.

It has been known that Depo-provera (DMPA) doubles the risk of HIV transmission (from HIV positive men to HIV negative women and from HIV positive women to HIV negative men) for more than twenty years. Yet the debates are still about whether it’s ‘preferable’ for women and men to risk infection with HIV than to risk unplanned pregnancy.

Problem is, those doing the debating have forgotten to ask the people most affected by this dilemma. Those most likely to be affected are often women and men in high HIV prevalence countries. Considering there are numerous alternatives to Depo-provera, it seems likely that a lot of people would choose to use one of them, and there would be no dilemma.

But UNAIDS take their customary position of supporting the pharmaceutical industry in their monthly ‘Science Now’, where they add a self-serving gloss to recent articles about HIV. The Lancet appears to prefer debating about whether there should or shouldn’t be a randomized controlled trial. One article in the journal argues that injectable hormonal contraceptives are the most widely used form of birth control.

But doesn’t that raise several questions, such as why Depo-provera injectable contraceptive is so widely used, especially in areas where HIV prevalence is high? To what extent have people been warned about the risks they and their sexual partner face? It appears that the views of those who are subjected to extremely aggressive marketing of DMPA are irrelevant to the debate.

Big pharma and their friends at The Lancet, UNAIDS, WHO and elsewhere have decided that people in developing countries should reduce their population at all costs, including risking being infected with HIV or infecting others. But there is no need to choose between these two: there are alternatives to Depo-provera that don’t increase the risk of HIV transmission.

Perhaps some are calling for the withdrawal of Depo-provera, but others are calling for those aggressively promoting injectable contraception, perhaps in order to further their ends of population control, vast profits and neocolonialism, to be properly regulated, and a full disclosure of known risks to be included on the packaging.

The pharmaceutical industry, the agencies that have been set up or co-opted to promote their interests, such as WHO, UNAIDS, various academic instutions, medical journals and the rest, do not ‘know best’. They can not be trusted to be left on their own to make good decisions about the health and lives of people in developing countries.

A senior epidemiologist at UNAIDS once argued that if unsafe healthcare was common in some African countries, hepatitis C prevalence in South Africa would also be high; the largest HIV positive population in the world is found there, but hepatitis C is not common. She insisted that HIV was mainly spread by heterosexual sex in Africa.

However, the simple answer is that hepatitis C was not around in South Africa to a great enough extent. If it had been around to any great extent it would have been transmitted sexually among the people who were said to engage in high levels of unsafe sex, as well as being spread by unsafe healthcare.

To the question of why HIV prevalence is not high in Egypt and other countries where hepatitis C was spread by unsafe healthcare, the answer is the same; HIV was not around to any great extent in Egypt when hepatitis was being spread. HIV arrived some time in the 1980s, after the injected treatment for mass schistosomiasis had been replaced by an oral dose. Otherwise HIV prevalence would be high in Egypt.

Recently I came across estimates of the ‘sex worker’ population in three countries with very different histories, Morocco, Kenya and South Africa.

*This is an urban estimate, covering all towns of 5,000 or more people

The explanation that UNAIDS and others in the HIV industry give for differences in HIV epidemics always relates to sex. The typical argument about why prevalence is so low in Morocco and other northern African countries is that the populations are almost 100% Muslim, with some even claiming that male circumcision also protects men from HIV.

The sex worker population in Morocco is smaller than those in Kenya and South Africa (although the numbers for Kenya do seem pretty high, considering the urban population only includes about one quarter of people). But it is the figures for HIV prevalence and people living with HIV that are completely out of proportion.

Prevalence in Kenya is 61 times higher than prevalence in Morocco and prevalence in South Africa is 179 times higher. Are we expected to believe that the very different environments and histories found in these three countries, emerging over many decades and centuries, all result in an impact on sexual behavior alone, and that is as staggering as these figures suggest?

Surely there are some other important differences? For example, infrastructure is much better developed in South Africa than in Kenya. But much of Morocco is desert. More importantly, the Sahara may have protected countries around it from HIV. Health services are also better developed in South Africa.

HIV established itself in East Africa in the 1950s and had infected hundreds of thousands of people by the 1970s. The virus was not established in South Africa until the 1970s and by 1990 prevalence was still very low. So the majority of the six million infections occurred after 1990. But HIV only arrived in Morocco in the 1980s, from Europe, and it never really spread that widely.

Perhaps sexual behavior in Muslim countries is different from sexual behavior in non-Muslim countries. But numbers of sex workers, men who have sex with men and others suggest that it could not be differences in sexual behavior alone that accounts for huge differences in HIV prevalence and numbers of people infected.

The histories of countries where HIV failed to spread can be as enlightening as those of countries where the virus spread widely when it comes to understanding why a few countries have appalling epidemics, whereas others have relatively small ones. HIV spread most successfully in southern Africa, less successfully in eastern Africa and not very successfully in northern Africa.

Some have suggested that HIV was spread by unsafe healthcare several decades ago, but that sexual transmission took over in the 1970s or 1980s and that it now accounts for 80% or more of all transmission. But there is no evidence for this anomalous transition, with healthcare suddenly becoming safe and heterosexual sex becoming rampant, but only in some countries.

Even UNAIDS themselves don’t believe that healthcare is safe in African countries. They warn their own employees to avoid ‘non-UN approved’ health facilities and people are advised to carry their own syringes and needles. Tourists from wealthy countries are similarly warned when they are travelling in African countries. So why are African people not warned about the risks and how to avoid them?

One of the remarks that many articles about the Cambodian HIV outbreak are mentioning now, almost as if every journalist is tweaking the same press release and putting their name on it, is about needlestick injuries and the CDC’s estimate that “99.7% of needlestick occurrences involving HIV infected blood do not result in transmission“.

This figure is irrelevant and entirely misleading: receiving an injection or an infusion is nothing like a needlestick injury when some or all of the equipment, or the substance being administered, are contaminated. Needlestick injuries are typically slight and shallow and the inoculant is likely to be very small.

Some of the titles also mention ‘tainted needles‘, but this may give the incorrect impression that reused syringes are not also a likely factor in this outbreak, along with contaminated multi-dose vials of medicines, vaccines, distilled water and other substances.

An injection involves the needle going below the skin, into muscle or into a vein, depending on what kind of injection it is. Most of the contents of the syringe and needle, along with anything remaining in them from previous uses, goes into the patient’s body. Some estimates of risks are given on this Don’t Get Stuck With HIV webpage.

Most of the contents of the syringe and needle enter the patient’s body. Some remains in the syringe and needle. In addition, it is possible for a vacuum to form in the syringe, allowing a small amount of blood from the patient to enter the syringe. To repeat, this is nothing like a needlestick injury.

Someone from the World Health Organization is reported as saying “different types of injection procedures carry different levels of risk“, which is a major improvement on the CDC quotes, but the WHO remark needs to be explained further, while the CDC one needs to be removed altogether.

Similar remarks apply to infusions, intravenous drips, etc. The risk of transmission from some common procedures can be very high indeed. Visitors to Cambodia may have noticed how popular intravenous drips are, with passengers on the back of motorbike taxis holding up the bag as they ride, and small ‘medical’ practices opening on to streets in Phnom Penh (although I doubt if many visitors have used such clinics because they tend to be aware of the risks of infection with HIV and other viruses through unsafe healthcare).

It is also very disturbing that the single practitioner said to have been involved in the outbreak has been arrested, imprisoned and even accused of murder (though little mention has been made of any murder victims). This is not going to encourage other practitioners, or professionals of any kind, political, administrative, ancillary, etc, to come forward and assist with the inquiry.

Members of the public may be careful what they say to police if they think others may be arrested and accused of murder. But even employees of CDC, WHO, UNAIDS and the like may be reluctant to find evidence that the risk of healthcare associated HIV transmission is very high, because they have been insisting for several decades that it hardly ever occurs.

To ensure the cooperation of as many health practitioners as possible the Cambodian authorities need to consider a ‘no blame’ investigation. Every article so far suggests confusion, professionals not recognizing HIV risks from unsafe healthcare, politicians appearing to know nothing about it and, more importantly, members of the public not knowing about the risks they face, or how to avoid them (there is some useful advice here).

It is especially important that members of the public are involved and that they understand a ‘no blame’ investigation. While some people may be angry about the single unlicensed practitioner identified so far, the entire health service, department of health, and even the global health community must share some of the responsibility.

Local human rights NGO Licadho stresses this point. The government of Cambodia (and governments of every developing country) have been claiming to have implemented ‘universal precautions’ to prevent healthcare associated HIV transmission. But is this a mere tick in a box marked ‘universal precautions’?

In the light of this and numerous other outbreaks, declarations about universal precautions may need to be questioned to establish if there is any mechanism for ensuring that these precautions are being followed, and even if it is possible to follow them in seriously under-resourced health services.

There has been a lot of wringing of hands and gnashing of teeth among the global health community about how the recent ebola epidemics in Guinea, Liberia and Sierra Leone may have been contained if only there had been universal healthcare (UHC) in place. Amartya Sen even makes a similar point in his excellent article on UHC in the English Guardian.

But this public angst seems to imply that around 20 earlier outbreaks of ebola were contained because health systems in the countries involved, Nigeria, Uganda, Sudan and the Democratic Republic of the Congo, were adequate. In fact, the opposite was the case in some instances, with several outbreaks dying out once the local healthcare facilities were overwhelmed and forced to close down.

Perhaps UHC, however vital, is not enough on its own? For the seven countries listed above, can anyone say that health services, while weak, are safe? An article just published on knowledge and practice of universal precautions among healthcare workers in Nigeria concludes that “the practice of universal precaution is not given much attention in [Primary Health Care] and this may constitute health risk to the nurses and the patients in the study setting“.

Nigeria is not alone; the Don’t Get Stuck With HIV site’s ‘Cases of HIV from Blood Risks’ section lists 17 African countries where healthcare related outbreaks have occurred, along with nine non-African countries. Cambodia will soon be added to the latter collection.

The number of people found to have been infected with HIV in Roka Commune, Battambang Province, probably through unsafe healthcare, possibly administered by an unlicensed practitioner, is now well over 230. But that number is already several days old.

More importantly, the inquiry appeared to go beyond the village where the first cases were found, as more turned up from other villages. Will the inquiry also look for outbreaks elsewhere around the country? Surely there are other unlicensed practitioners, other practices where safety is not the priority it should be?

In addition, there may be licensed practitioners and practices where risks are being taken. Perhaps few people have been infected as a result, perhaps none; but if unsafe practices are to be found anywhere in the country there is a risk that there will be other outbreaks in the future.

There have been no serious investigations of healthcare associated HIV outbreaks in African countries, where all the worst epidemics are to be found. The countries where there have been investigations are mostly ones where the global health community does not have a lot of influence, such as China, Kazakhstan, Uzbekistan and Kyrgyzstan.

An investigation carried out in 2008 in Pakistan after a very large number of people tested positive in this low prevalence country was too superficial to identify any additional infections, although the outbreak was clearly a result of unsafe healthcare. Here too, the finger was pointed at a few unlicensed practitioners, leaving licensed healthcare out of the picture altogether.

None of the media reports from Cambodia suggest that journalists are making any attempt to go beyond what they are fed in the form of press releases. They could quite easily ask people in any village in the country, or even in the cities, about unlicenced practitioners and practices. But the implications of this outbreak seems to be entirely lost on them.

The Australian media, in particular, has had little to add to the subject, although Cambodia is dominated by Australian NGOs, NGO workers, expats of various kinds, business people, tourists and the like. Australians are less likely to visit unlicensed practitioners or practices, but levels of safety in licensed healthcare are unknown.

The UN and its employees are not in any danger, of course, because they are all issued with advice, even injecting and other equipment when they visit certain areas. They have their own UN-approved health facilities and would rarely any serious healthcare risks.

The press may continue to wait for the scraps that will eventually be thrown to them, or they could carry out their own investigation into healthcare safety in the light of the outbreak of healthcare associated HIV in Battambang Province. But they may end up missing a cover-up on the same scale as the one that appears to have gone unnoticed by the press in Pakistan a few years ago.

If there was an injectible birth control method that doubled the risk of HIV positive people using it infecting their partner, and also doubled the risk that HIV negative people using it would be infected themselves (if their partner is infected), you’d expect the WHO to issue a warning, right?

But Depo-Provera (DMPA) is widely marketed by NGOs and other institutions running family planning programs in developing countries, and WHO (World Health Organization) evidently believes that reducing births is more important than safety.

This is great for Pfizer, and now, thanks to their new symbiotic relationship, it’s great for Gilead too, because women using Depo-Provera may be able to reduce their risk of being infected, or of infecting their partner. All they have to do is take drugs kindly produced by Gilead, in the form of pre-exposure prophylaxis (the use of antiretroviral drugs, either daily or intermittently, to reduce the risk of infection with HIV).

You might think that this would not happen, that surely, Depo-Provera would be taken off the market, or at least carry a warning. But companies such as Pfizer and Gilead have been very successful in getting institutions like the WHO, along with various universities and donors (such as those listed in the AIDS Journal article), to help them market their products.

PrEP is something of a solution in search of a problem. It is possible that HIV negative people who wish to have unprotected sex with HIV positive people (or people whose status is unknown) would be able to reduce their risk of being infected. But the majority of people in African countries are probably not in this position; PrEP is likely to be more of a recreational drug for wealthy countries.

If people wish to reduce their risk of being infected with HIV (or of infecting others) they would be well advised to avoid Depo-Provera. There are plenty of other birth control methods, some of which also protect against HIV and various sexually transmitted infections.

The problem is that HIV positive people using Depo-Provera and HIV negative people whose partners use it are not being warned about these well documented risks. They are not suffering from a lack of pre-exposure prophylaxis, but they might be suffering from poor, incomplete or biased family planning advice.

There are industry sponsored trolls on social media sites, Twitter for example, who pounce on anyone who tries to question the safety of Depo-Provera. But the above AIDS Journal article seems to confirm what critics have been saying, while at the same time offering another patented solution that can be taken in conjunction with the discredited birth control method.

In contrast to PrEP, Depo-Provera seems to be almost exclusively marketed to poor people in rich countries and to anyone and everyone in poor countries. No conflict of interest is declared in the peer-reviewed journal that published the paper, and the donors listed are all well known and highly influential, particularly in relation to Depo-Provera studies.

According to an article in the UN’s IRIN News “West Africa’s Ebola epidemic has cruelly exposed the weaknesses of health systems in the countries where it struck”. The director of the World Health Organization, Margaret Chan, is further quoted as saying that “what they lacked was a robust public health infrastructure to deal with the unexpected”.

This is a very odd way of looking at the situation. Firstly, almost every country in Africa lacks a robust public health infrastructure; secondly, most of them have lacked such an infrastructure for many decades, as a cursory review of relevant literature, going back at least to the 1940s, will reveal.

Tens of millions of people suffer from numerous avoidable health problems, such as malnutrition, vitamin deficiencies, parasitic conditions, infectious diseases, non-communicable diseases and more; epidemics and outbreaks are so common that most of them don’t even hit the headlines, least of all the headlines of non-African newspapers.

Not only that, but this has been the case throughout the whole of the WHO’s history. Lack of health infrastructure to deal with the ‘unexpected’ has been the norm in sub-Saharan Africa for decades, as the WHO (as an institution) can confirm. They were involved in various campaigns to reduce or even eliminate some health conditions, sometimes successfully, sometimes not so successfully.

In fact, many of their less successful forays into eliminating or eradicating diseases demonstrated that it is not possible to ensure that diseases can even be eliminated from large areas without adequate health infrastructure, let alone eradicated. Various programs to reduce prevalence of certain sexually transmitted infections were unsuccessful precisely because of failures relating to overall health infrastructures, rather than to any weaknesses in the programs concerned.

The HIV epidemic has raged in many sub-Saharan African countries regardless of various expensive and well publicized programs to reduce transmission. Some country epidemics have declined, but many did so before the bulk of prevention campaigns were even dreamed up; in other countries there are few credible causal links between HIV prevention programs and drops in transmission rates.

Chan would be better off asking why the ongoing ebola epidemics in West Africa are so much worse than any that have occurred elsewhere. It would also be interesting to know why HIV epidemics in West African countries were so much less severe than in African countries that are said to have far better developed health systems than Sierra Leone, Guinea and Liberia, such as South Africa and Botswana.

Chan goes on to bemoan lack of “background data on the usual…so that the unusual stands out”. I’ve been reading articles about sexually transmitted infections in African countries published between the 1940s and the 1990s. Most of them attest to the lack of reliable information and statistics. ‘The usual’ is what you find in the three countries who have suffered the most in the current epidemic: health systems in most other African countries are in a similar state.

Decades of epidemics have, apparently, yet to teach us that you are unlikely to be able to mount a successful campaign against disease outbreaks if you don’t have well developed health infrastructures. You can’t hurriedly put everything together in a package and send it off with some soldiers, so they can piece it together before heading off to their next dig a hole and fill it in scheme.

Chan is right in demanding “good quality care [that is] accessible and affordable to everyone, and not just to wealthy people living in urban areas; having enough facilities available in the right places with enough well trained staff and uninterrupted supplies of essential medicines; diagnostic capacity that returns rapid and reliable results; and information systems that pinpoint gaps and direct strategies and resources towards unmet needs”.

But she should start by taking a close look at those villages in Cambodia where several hundred people have been infected with HIV through unsafe healthcare. There is little point in developing health infrastructures without ensuring that they are also safe. Otherwise, she may end up with another Egypt on her hands, which has the highest prevalence of hepatitis C virus in the world following an otherwise successful schistosomiasis eradication campaign.

The ongoing inquiry into an outbreak of HIV in several Cambodian villages has so far found more than 160 cases. Most cases were found in one village, but 20 were found in a nearby village and a few more in a third.

However, the inquiry needs to be expanded to include all villages where such an outbreak may have occurred. It also needs to be expanded beyond unlicensed premises and practitioners. It should include all health facilities, pharmacies, practices and anywhere skin piercing procedures take place.

The reason the inquiry needs to be so broad is that anyone in the country may be as ignorant as their esteemed leader, Hun Sen, about the risk of being infected with HIV through unsafe healthcare. Many people may only have heard about sexual risk; those who have heard about non-sexual risks have probably heard that it is very unlikely, which is the received view propagated by UNAIDS, WHO, CDC and the like.

Also, the CDC estimates for the risk of being infected through reused injecting equipment seem unbelievably low. They claim that the risk from needle-sharing during injection drug use is 63 in 10,000. The one unlicensed practitioner arrested so far has admitted to reusing syringes and needles, so the risk may be similar to that faced by injection drug users. But compare those CDC figures to estimates on the Don’t Get Stuck With HIV site.

If the risk is as low as CDC’s 63 in 10,000 then this single unlicensed practitioner must have an impossibly large number of clients, who receive a lot of treatment that involves skin piercing of some kind. It is far more likely that other practitioners, licensed and unlicensed, also take risks. Yet, infections will only be brought to light if the investigation is broad and thorough enough.

The investigation also needs to report honestly. Hun Sen may wish to protect his country’s image of one that has avoided a very serious HIV epidemic; UNAIDS may wish to continue denying non-sexual transmission through unsafe healthcare; CDC may not want to review their estimated risk, for whatever reasons, etc.

But the most important thing is to discover how people have been infected, then cut off these routes to infection. This kind of outbreak could happen again and again, because neither practitioners nor members of the public are being warned of the risks of infection through reused medical instruments and other unsafe practices.

The investigation so far has demonstrated one of the dangers of the sort of culture of blame that has been developed by UNAIDS and the HIV industry. If those found to be engaged in unsafe practices are persecuted, threatened, imprisoned or otherwise punished, the investigation is unlikely to bring too many outbreaks and unsafe practices to light.

Those already infected need to be identified, and given treatment and support. Those at risk, likely to be a very large number of people, need to be proteted from harm.

The arrest of a single practitioner to date looks like a case of scapegoating, somewhat resembling Libya’s reaction when an outbreak was discovered there, or the Ugandan nurse sentenced to several years in prison for ‘negligence’ because she is said to have risked infecting an infant with HIV (she was released after serving nearly one year but the conviction was upheld).

Condemnation of those engaging in unsafe practices, when the HIV industry itself has failed to warn practitioners and patients about the risks, is entirely misplaced. It only adds to a systematic failure to protect people from being infected, as well as exposing health practitioners and others to abuse and accusations of ‘deliberate’ transmission of HIV.