Bloodborne HIV: Don't Get Stuck!

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Category Archives: AIDS

Unsafe Sex and Unsafe Healthcare are Mutually Exclusive HIV Risks in African Countries?


Recently, I blogged about a series of investigations that took place in various US states over a period of 10 years because of 86 cases of hepatitis C infection (HCV) being discovered, which could not be explained by the usual risks for this virus in a wealthy country, namely intravenous drug use and the like.

This extremely comprehensive investigation revealed that the 86 infections resulted from the actions of just six health personnel, who all had an addiction to controlled drugs. Over the course of 10 years they had put the safety of an estimated 30,000 patients at risk.

When a young woman in Brazil was found to be infected with HIV and no obvious sexual risks were established, rigorous research was carried out to discover a possible mode of transmission. The research found that the woman may have been exposed to contaminated manicure instruments many years before.

The manicure instruments belonged to the patient’s cousin, who had been on antiretroviral drugs, but whose treatment had lapsed. Phylogenetic analysis showed that the patient had very likely been infected by this cousin, and that sharing contaminated manicure instruments was the most likely mode of infection.

Worryingly, the paper finds that “In a recent case of transmission among women, the CDC lists, along[side] classical transmission routes, potential alternative sources that must be ruled out, such as tattooing, acupuncture, piercing, the use of shared sex toys between the partners and other persons, and exposure to body fluids, but does not include manicure instruments.”

The use of shared sex toys but not other shared instruments? Forgive me for thinking that people working for the CDC and other normative agencies may have some unresolved issues relating to assumed sexual practices, and perhaps an aversion to discussing non-sexual risks; or maybe that’s just when it relates to African countries?

Although an estimated 70% of HIV positive people live in sub-Saharan Africa, the kinds of investigation that were carried out in the US and Brazil do not appear to have been carried out in any African country. At least, if they have been carried out, they have not been written up in peer-reviewed papers.

Anyone who has visited Kampala in Uganda or Moshi in Tanzania may have seen people with basins of manicure equipment being used in the open, in shops and other premises, on women waiting for buses, working, shopping or just taking some time for a manicure or pedicure.

In Dar es Salaam and other places you may see men shaving another man’s head with a hand held, double edged razor. When one has finished, they swap around. Little nicks and cuts are usually treated with a piece of tissue, or possibly with a bit of antiseptic.

However, when people are diagnosed with HIV in African countries they are generally not asked about their possible non-sexual exposures, through unsafe cosmetic, traditional or healthcare practices. When people say they have not had sex, that they have not had sex with a HIV positive person, or that they have only had protected sex, these matters are generally dismissed.

HIV is not the only pathogen that is possibly fairly frequently transmitted in cosmetic, traditional and healthcare contexts, where skin-piercing is involved. Other pathogens include hepatitis, various bacterial infections, scabies, even ebola. Where skin-piercing is not involved, also, several serious diseases can be transmitted in these environments, for example TB.

It seems that, because it’s Africa, sex is always imputed, even when the patient makes it clear that this may not be, perhaps even cannot be, the mode of transmission. Because it’s Africa, unsafe healthcare, it seems that cosmetic and traditional practices can not explain otherwise inexplicable HIV infections.

According to normative agencies such as UNAIDS, healthcare and other environments are unsafe enough to explain high prevalence of hepatitis C in several low HIV prevalence countries, such as Egypt, but can’t explain high HIV prevalence in a low HCV prevalence country, such as South Africa.

Why should healthcare be unsafe and sexual behavior safe in all and only the countries with high HCV prevalence in Africa, while healthcare is safe and sexual behavior unsafe in all and only the countries with high HIV epidemics? Also, if sexual behavior is so unsafe in sub-Saharan Africa, shouldn’t HCV prevalence also be high all high HIV prevalence countries?

Hepatitis, TB, HIV and Ebola: Healthcare Associated Epidemics?


It is sometimes claimed (by UNAIDS and others) that if HIV was frequently transmitted through unsafe healthcare in sub-Saharan countries, then hepatitis C (HCV) would also be common in the same countries, because HCV is usually transmitted through unsafe healthcare (dental procedures, surgery, stitches, etc). Indeed, HIV prevalence is often higher in countries that have low prevalence of HCV; and the high HCV countries tend to have low HIV prevalence.

However, given that it is well established that both viruses can be transmitted through unsafe healthcare, and that unsafe healthcare practices are probably very common in most (all?) African countries, the non-correlation between HIV and HCV prevalence seems like a very weak and unappealing argument. Because we don’t know the relative contribution of HIV transmission through unsafe healthcare, neither do we know how much transmission is a result of heterosexual sex.

Blaming high rates of HIV transmission almost exclusively on ‘unsafe’ heterosexual behavior has a number of dangerous consequences. For a start, it stigmatizes those who are already infected. It also results in people who don’t engage in ‘unsafe’ sexual practices failing to recognize their risk of being infected. More serious still, it means that public health programs aiming to influence sexual behavior will be relatively ineffective.

HCV prevalence in Egypt is the highest in the world and HIV prevalence is low. But a recent survey concludes that “Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt“. It sounds like measures to reduce transmission have not yet been completely successful. More worryingly, another paper finds that “there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities“.

What about countries where HIV prevalence is extremely high, such as South Africa? HCV prevalence is very low, so the UNAIDS argument above would suggest that unsafe healthcare does not play a significant role in HIV transmission. But does that mean unsafe healthcare is unimportant? After all, resistant strains of TB have been transmitted in hospitals in South Africa and this has even spread beyond South Africa, to surrounding countries, and even to another continent.

In reality, we don’t know that much about HCV in the Africa region. A review of research on the subject concludes that “Africa has the highest WHO estimated regional HCV prevalence (5.3%)” in the world. That’s a striking figure, because HIV prevalence across the whole sub-Saharan African region is also around 5%. There are two serious viral pandemics on the continent that may both be driven to a large extent by unsafe healthcare.

HCV concentrates in certain countries and in parts of certain countries. But so does HIV. Prevalence is relatively low in most of Kenya, for example, only a few percent. It’s high in the two large cities, Nairobi and Mombasa, and highest in three (out of 47) counties around Lake Victoria. The situation in Tanzania is similar, with three high prevalence areas. In Burundi and Rwanda prevalence is also low, except in the capital cities.

So the fact that most high HIV prevalence areas do not overlap much with high HCV prevalence rates is not a very convincing argument that the two viruses are transmitted in completely different ways, the former being mainly transmitted through heterosexual sex and the latter through unsafe healthcare. Comparing HCV and HIV patterns only makes the contention that HIV is mostly sexually transmitted look all the more infantile.

The good news, then, is that improving healthcare safety would reduce transmission of both HCV and HIV, and even a range of other diseases that don’t get anywhere near as much attention as HIV. Good healthcare is also safe healthcare, whereas indifferent healthcare, with low standards of infection control, results in alarmingly high rates of transmission of serious diseases.

Journalists have recently had their attention drawn to the potential drawbacks of neglecting healthcare; ebola is difficult to control in a healthcare environment (as opposed to a rural village, where it appears to die out quite quickly). But it has been shown that it is difficult to control in healthcare facilities because of unsafe practices, such as reuse of skin-piercing instruments, gloves and other disposable supplies, lack of infection control procedures, a shortage of skilled personnel, etc.

One newspaper article even made a connection between ebola and HIV, suggesting that because many West African countries had relatively low HIV epidemics, investment in healthcare was lower, hence the weakness of the response to ebola.

Their analysis is not very perceptive. HIV-related investment in Sierra Leone and Liberia has been high enough to ensure that more than 80% of HIV positive people are provided with antiretroviral treatment. Guinea is way behind them in this respect, with less than 50% of people receving treatment. But spending money on preventing supposedly sexually transmitted HIV, and on treatment, does nothing to address unsafe healthcare.

HCV, HIV, ebola, TB and various other diseases can be transmitted through unsafe healthcare, so this is an argument for strengthening all health facilities in all developing countries. A human right to health does not make any sense if healthcare is so unsafe that patients risk being infected with a deadly disease when they visit a health facility. So ‘strengthening’ healthcare must include making health facilities safer.

It is hardly surprising that people in Guinea, Sierra Leone and Liberia run from health authorities and hide family members who are sick. The prospect of having your house searched by people in hazmat suits, sometimes backed up by people with guns, is frightening enough. But if your property is dragged outside in broad daylight and burned in public, and your sick relatives are hauled off to a ramshackle, understaffed, undersupplied health facility, these must extremely traumatic experiences.

If health facilities are unsafe, healthcare associated transmission of serious diseases will only increase as more people are admitted to them. Transmission rates will not go down until safety is made a priority; this applies as much to HIV as it does to HCV, ebola, TB and other diseases. The additional assurance that people will not be exposed to life-threatening diseases through unsafe healthcare should also increase demand for healthcare.

Uganda’s HIV Prevention and Control Act May Fall Foul of Itself


The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.

It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.

But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.

In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don’t Get Stuck With HIV site.)

The act makes no explicit mention of non-sexual transmission through healthcare, cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.

The above incidents raise questions about the act’s definition of ‘informed consent’, which requires that people be given “adequate information including risks and benefits of and alternatives to the proposed intervention”. Were mothers informed about all of  the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?

Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.

The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.

Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn’t always protect them from conviction.

Part one of section 45 reads: “All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification”; part three reads: “A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction…”.

So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.

CDC: Ebola Characterized by ‘Amplification in Health Care Settings’


When Peter Piot, the ‘Virus Detective Who Discovered Ebola‘, went to one of the first identified outbreaks in 1976 in the Democratic Republic of Congo, he reported that “it was clear that the outbreak was closely related to areas served by the local hospital”.

Piot says: “The team found that more women than men caught the disease and particularly women between 18 and 30 years old – it turned out that many of the women in this age group were pregnant and many had attended an antenatal clinic at the hospital.”

He goes on: “The team then discovered that the women who attended the antenatal clinic all received a routine injection. Each morning, just five syringes would be distributed, the needles would be reused and so the virus was spread between the patients.”

What he has to say about people getting ill after attending funerals is repeated in contemporary reports on ebola in West Africa, ad nauseam. But the comments about visits to the hospital, women attending antenatal care and reuse of syringes (and possibly other medical instruments) are no longer mentioned so much.

The CDC does write that ebola “has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment“, but they are not as expansive as Piot about exactly what that means on the ground.

There was a whole rash of recent reports about women being more likely to be infected with ebola than men in the current outbreak and a rather narrow set of speculative explanations about why this might be so, one being that women are more likely to be involved in giving care than men.

While women may well more often be the ‘caregivers’, an article in the New England Journal of Medicine summarizes available data on every reported case. However, it finds that there is very little difference in the numbers of men and women infected, and even the number of men who die from ebola.

There are also far fewer children infected than adults, despite claims that ‘women and children’ are more likely to be infected than men.

As far as I can see, media speculation into why women may be more likely to be infected than men (because they may have been more likely in some instances) did not question the possibility that women are often more likely to access healthcare, especially when pregnant.

Piot makes this connection during the first investigated ebola epidemic and goes on to connect women’s elevated risk with the use of unsterile syringes, not just casual contact in healthcare facilities.

It is to be hoped that clinics are no longer issued with five syringes a day, though clear data about supplies of syringes and needles is hard to come by. But what about other infection control equipment and supplies; especially equipment and supplies in facilities that are experiencing extreme shortages?

What about facilities that are understaffed, where an adequate number of workers may be able to take certain precautions to protect themselves and their patients, but an inadequate number may only be able to think about their own safety, or not even that?

In the case of HIV there are many reasons why a woman might be more likely to be infected through unsafe healthcare. They are expected to attend antenatal care during pregnancy, give birth in a health facility, attend post-natal care, and perhaps several other reasons.

But since western countries, especially the US, have started taking an interest in ebola, they have reinforced efforts to round up people who look in the least bit like they have a fever and sticking them in an already overcrowded health facility, where conditions are appalling.

So if women were more likely to be infected with ebola earlier on in the current epidemic, and in some of the earlier outbreaks in other parts of Africa, perhaps the current approach is influencing the gender balance somewhat. One result possibly being that men are no longer less likely than women to go to a health facility (especially if they are given no option).

Piot says: “The closure of the hospital, the use of quarantine and making sure the community had all the necessary information eventually brought an end to the epidemic – but nearly 300 people died.” Most people were quarantined in their own homes, not in an overcrowded and filthy ward.

How things have changed. Far from trying to persuade people to stay in their homes and supporting family members to look after them, US soldiers are helping to send people to what could be the very epicenter of the epidemic.

There are now far more confirmed and suspected ebola cases than there is hospital capacity to care for them. So a strategy that aims to strengthen and make hospitals safer, in combination with strengthening communities to care for people at home might now be the only option left.

Guardian Ebola Coverage: More Journalism, Less Journalese, Please


My last post cited an article from the English Guardian claiming that a two year old boy had been bitten by a fruit bat and thus became ‘patient zero’ for the current ebola epidemic in West Africa. Since then, the newspaper has rewritten the paragraph to read:

In December last year, near the village of Meliandou in southern Guinea, two-year-old Emile may have come into contact with one of the fruit bats that fly through west Africa’s skies, often gathering at dusk to roost in trees.

‘May have come into contact with’ is a lot better than what Clar Ni Chonghaile wrote previously, but the article still confidently claims that this two year old boy is ‘patient zero’. An article in the New England Journal of Medicine shows that this confidence is mislpaced:

Potential reservoirs of [ebola], fruit bats […] are present in large parts of West Africa. Therefore, it is possible that [ebola] has circulated undetected in this region for some time. The emergence of the virus in Guinea highlights the risk of [ebola] outbreaks in the whole West African subregion.

An infectious disease doctor at CDC goes further: [these] two kids were likely early cases of the outbreak but not the first cases.

My criticism of Ni Chonghaile is not that she is wrong about bats or patient zero, but that she infers some kind of certainty where there are at best hypotheses, and at worst pure speculation. I accept fully that epidemiology is often like that, therefore I object to the use of ‘fruit bats’ and ‘funeral practices’ as explanations when these are probably a very small part of the story.

Although it is not my purpose to check ‘facts’ in the article, I would also say that timing is very important; it matters a great deal when the first suspected case was reported, whether they survived, when the next case was reported, etc. So it is worth pointing out that Ni Chonghaile also gets the dates wrong: the symptoms started for the first suspected case on December 2, not December 26; he died four days later. [Correction: the NEJM article gives two possible dates, one in early December and the other in late December, with consequent changes in the possible dates of infection of other suspected cases.]

But the most important thing that Ni Chonghaile and others writing on the subject fail to discuss is the possibility that unsafe healthcare is likely to have played a considerable role in transmitting ebola. Infection from healthcare worker to patient, as well as from patient to healthcare worker, are very likely, so is infection from patient to patient. What about reused syringes, needles and other equipment? Even reused gloves?

Naturally, the Guardian and other media outlets decry conditions in health facilities in African countries in the abstract. But concrete evidence that unsafe healthcare may have been responsible for transmitting HIV, hepatitis, TB and other diseases in the past, and may still be responsible, doesn’t seem to impinge very much on their ostensibly enlightened consciousness.

Eliminating contact with bats, funeral rites and a handful of other exotic phenomena will not, have not, stopped the epidemic. Sure, a bat (or some other animal) may have started the current outbreak, but how has it been sustained since then (whenever that may have happened)? This is not at all about blame, but about tracing how each infection occurred and eliminating that mode of transmission.

These trivial ‘certainties’ deflect attention from a host of uncertainties, but also from the unspoken suspicion that the current approach itself is not working, that protocols may be incomplete, that the proposed solution may be part of the problem. It should not be beyond a journalist to question things that seem to be relevant, but are currently being ignored. Or perhaps I expect too much from them?

Patient Zero, Perfect Storms and Other Comforting Epidemic Metaphors


The English Guardian reports: “In December last year, near the village of Meliandou in southern Guinea, two-year-old Emile was bitten by one of the fruit bats that fly through west Africa’s skies, often gathering at dusk to roost in trees.” In fact, as the article goes on to make (partially) clear, this is just one hypothesis out of many.

The ‘first’ person infected in the current outbreak may or may not have come into direct contact with a bat, or some other animal; or the outbreak may have occurred in a health facility, rather than in ‘the bush’; the term ‘Patient Zero’ is suitably dramatic for articles about disasters set in exotic locations, but has distracted attention from how people continue to be infected with ebola.

It’s comforting to think that African two year olds are a lot less likely to be bitten by bats now that the scientists, medics and disaster workers have moved in; perhaps African parents will even give up or modify their unsafe bat-hunting habits and take people to hospital if they are thought to be sick, and cease to take vaguely defined risks of being infected at funerals.

Meanwhile, when a healthcare worker in Texas is infected with ebola, being one of the many people who nursed ebola victim Thomas Duncan, a ‘breach of protocol’ is immediately suspected. Another hypothesis, of course (although it leaves out the possibility that the protocol has failed to take into account some additional mode of transmission).

Compare this to an earlier blog post: when 86 people who have no identifiable risks for the virus are infected with hepatitis C in the US, expensive investigations are carried out into possible breaches of infection control processes in the health facilities that the victims attended.

Yet, when millions of Africans who have no identifiable risks for the virus are infected with HIV, an entire industry develops around the prejudiced view that Africans engage in huge amounts of unsafe sex. No investigations are carried out into conditions in health facilities, although various reports show that infection control processes are seriously lacking.

Of course, there was no ebola protocol in West Africa back in December of last year. But all the more reason, then, to investigate health facilities. What kind of infection control processes were in place then, and are now? Subsequent findings suggest that there are severe shortages in trained personnel, supplies and beds, etc, similar to those noted in other African countries.

Rational explanations in western countries, but metaphors and non-rational backstories in Africa. Spacesuits, because it is an exotic virus from a different planet, brave westerners, but only poor and uneducated Africans.

It just seems a bit suspicious that ebola (and HIV and other diseases) are spread through the ignorance and carelessness of victims in African countries, but through a ‘breach of protocol’ in the US. Health facilities are such dangerous places in African countries that it is surprising authorities insisted on rounding up those suspected of being infected with ebola and marching them off to a clinic in the first place.

But that approach may now be challenged if this article in the New York Times is at all correct. It says that officials have admitted defeat and that they are going to “help families tend to patients at home”. About time too. This could be a major turning point if it is taken to its logical conclusion (if logic if given a role, for a change).

As David Gisselquist has pointed out on this site, people are not being asked about possible infection through through healthcare procedures they may have received in the recent past. Gisselquist has been arguing that people should be warned about healthcare risks, treated with respect and fully supported if they decide to care for ebola patients at home.

Long before the current ebola outbreak occurred it was already common practice for healthcare professionals to say as little as possible about lack of safety in facilities, resulting in HIV, hepatitis, TB and other diseases being transmitted through various procedures, such as injections with reused syringes and needles, unsterilized equipment, reused gloves and other materials. This needs to change, as the ebola outbreak shows (and as the hepatitis and HIV epidemics have been demonstrating for several decades).

In the US there are possible insurance claims, professional negligence inquiries, outbreak investigations, protocols to be rewritten, with some of these phenomena possibly being mentioned in the mainstream media from time to time. Oh, and perhaps some much loved mongrels to be euthanized.

But in Africa the media will continue with its customary approach: treat the people as an exotic, primitive species, to be pitied for their funeral practices and ‘bush meat’ hunting, their reluctance to go to a hospital (implied to reflect a suspicion of modern or ‘western’ things or people), etc. There will be lots more ‘ebola orphans’, two year old Emiles, ministering angels in spacesuits and the like.

It’s as if this completely unforseeable ‘perfect storm’ (a metaphor also favored by the media when writing about HIV) took away Patient Zero, and the rest of the outbreak was down to a combination of other ineluctable processes. But, whereas a perfect storm is a rare combination of factors, unsafe healthcare has been around for decades.

The current ebola outbreak is a symptom of decades of unsafe healthcare; it is nothing like a ‘perfect storm’. Two year old Emile, ebola’s putative patient zero, is as far from being the index case as Gaëtan Dugas was for the HIV epidemic. Stopping ebola requires an admission that unsafe healthcare spreads disease and allows isolated outbreaks to become pandemics. Apologies if the truth is far too prosaic to sell newspapers.

Amnesty International South Africa: Right to Healthcare Futile Unless it’s Safe Healthcare


When I was writing yesterday’s blog post I didn’t realize that the Amnesty International report I referred to had already been published. It’s called ‘Struggle for Maternal Health: Barriers to Antenatal Care in South Africa‘. It is quite extraordinary that such a lengthy report about maternal health can fail to mention safety, unsafe healthcare, healthcare transmitted infections and the like.

But the report puts the cards on the table on page 21: “Heterosexual sexual intercourse is the main cause of HIV transmission in South Africa.” The South African ‘National Strategic Plan’ is cited in support of this contention, and that document doesn’t really support the claim at all, although it’s clear that it comes from the usual documents from the usual normative agencies.

Normative agencies such as UNAIDS, WHO and others make guesstimates of the proportion of HIV transmission that can be attributed to male to male sex, intravenous drug use, commercial sex work and various heterosexual ‘groups’ (who are never very clearly defined). The minute figure that remains, 1-2%, is attributed to healthcare transmission of HIV.

But as yesterday’s blog (and other data on the Don’t Get Stuck With HIV site and blog) show, there are numerous types of healthcare transmission of HIV, including antenatal care, invasive forms of contraception, blood tests, donations and transfusions, child delivery, injections, surgery and many others.

Amnesty and others go on about stigma, the need for privacy, lack of information and poor public transport for pregnant women. But the stigma is not very surprising: if a HIV negative man constantly hears that the virus is primarily transmitted through heterosexual sex and that his wife is HIV positive, or that his child is, he is not being irrational in believing that his wife has been having sex with someone else.

Rather, he is misinformed. Misinformed by the likes of UNAIDS, WHO and, it seems, Amnesty International. Neither the woman nor the man are told that HIV may have been transmitted through some non-sexual route, perhaps even through unsafe healthcare. This is an especially important mode of transmission in the case of HIV positive infants whose mothers are negative, or HIV positive mothers whose partners are negative.

The closest Amnesty International’s report gets to the issue of unsafe healthcare is where they recommend “[paying] particular attention to the need to develop, resource and implement programmes to address the underlying determinants of health that promote safe pregnancies and deliveries.” [my italics] But there is little or nothing in the body of the report indicating that unsafe healthcare may be an underlying determinant in much of the morbidity and mortality among women, infants and children.

The report does talk to healthcare users and providers and there are some useful findings. People are not given clear, complete or even accurate information a lot of the time. Healthcare workers often lie or withhold vital information and they may even be ignorant of certain matters themselves.

Antenatal care provision may be lacking in South Africa, but the country has one of the highest figures for women giving birth in a health facility among all the high HIV prevalence African countries. It also has one of the highest figures for deliveries being attended by a skilled health provider.

In other words, high HIV prevalence countries tend to be those with better antenatal care indicators, rather than worse. Amnesty also reports on transport, but transport infrastructure is more developed in SA and other high HIV prevalence countries than it is in East and central Africa, where HIV prevalence is also lower.

Amnesty International did not seem to question these phenomena, despite the fact that they have noticed that HIV prevalence is high in SA, especially in the areas they did their research (KwaZulu Natal and Mpumalanga), also that maternal morbidity and mortality are much higher among HIV positive than HIV negative women.

Had they questioned the often cited but never demonstrated reflex ‘heterosexual intercourse is the main cause of HIV transmission’, they might also have tried to find out if health professionals may be hiding behind patient confidentiality and privacy and deliberately avoiding testing partners of HIV positive women because they wouldn’t want anyone to suspect that unsafe healthcare can be responsible for transmitting HIV.

These both look like conflicts of interest for healthcare providers, between informing HIV positive people how they or those they care for may have been infected and avoiding the suspicion that unsafe healthcare can result in transmission of HIV, hepatitis, bacterial infections and other pathogens (including TB, ebola and anything else going around in hospitals).

South African’s constitution holds that healthcare should be of ‘good quality’ and that citizens have the right to the highest attainable standard of health. Unless health facilities are safe places, increasing access to healthcare may be counterproductive and expose people to avoidable illness and injury. Unless healthcare personnel are enabled to provide safe healthcare, training and retraining them may be similarly counterproductive.

A well funded and experienced human rights NGO such as Amnesty International must go beyond the corporate mythmaking of normative agencies, the views of people constantly bombarded with misinformation and prejudice about HIV transmission, and health professionals who are either ignorant about healthcare transmission or who wish to protect their profession from suspicion of infecting patients.

Healthcare Transmitted HIV: Informed Consent and Conflict of Interest


Research in Mozambique, Swaziland and Kenya has shown that a substantial proportion of HIV positive infants have HIV negative mothers. These infants are likely to have been infected through unsafe healthcare, perhaps reused syringes, needles or other equipment, lack of adherence to infection control procedures, etc.

Amnesty International has launched a campaign to gather information from the public about maternal deaths in Mpumalanga, South Africa. In particular, they are interested in HIV testing, informed consent and whether consent is given voluntarily.

But what kind of ‘information’ are Amnesty collecting? The South African Medical Association’s Ethical and Human Rights Guidelines on HIV and AIDS makes no mention of non-sexual transmission of HIV whatsoever. Is information about the likely source of an infant’s infection not considered to be a vital part of giving informed consent?

Is information about how a mother (or anyone else) may have been infected with HIV not also vital? I would suggest that this information needs to be a standard element in pre- and post-test counselling for everyone, but particularly where the spouse is not HIV positive or where a HIV positive person has no identifiable sexual risks, is not an intravenous drug user, etc.

The Health Professions Council of South Africa’s (HPCSA) Guidelines for Good Practice in Medicine, Dentistry and the Medical Sciences has this to say:

The risk of transmission of HIV infection in the health care area from patient to patient, patient to health care worker, and from health care worker to patient through inoculation of infected blood or other body fluids has been shown scientifically to be very small. Fears, which are not always based on reality, have thus tended to exaggerate the risks out of all proportion.

This paragraph is not backed up by any citations and is expressed in language that is out of place in a set of guidelines for health professions; the word ‘scientifically’ is especially incongruous. What does it matter how small a risk of healthcare transmission of HIV is when an infant is HIV positive and the mother and their partner are not? Adults, also, could face healthcare and other non-sexual risks, but are these risks assessed by practitioners who have been told that they are ‘very small’.

The Mozambique research further shows that some HIV positive mothers were likely to have been infected by their HIV positive infants, that HIV negative mothers with HIV positive infants have not been told how their infants may have been infected, that HIV negative mothers have not been told that they can be infected by their HIV positive infants, that some mothers have been allowed to believe that their infant’s HIV positive status is their fault and that some healthcare workers are unable to answer, or even question, these phenomena.

The HPCSA General Ethical Guidelines for the Health Care Professions lists as one of the duties to patients: “Make sure that their personal beliefs do not prejudice their patients’ health care.” Personal beliefs about how the patient may have been infected with HIV, even beliefs based on the HSPCA Guidelines, should not preclude an unprejudiced assessment of both sexual and non-sexual exposure to HIV.

Amnesty International would do well to consider the possible conflicts between the interests of the healthcare professional and the interests of the patient in regard to providing those being tested for HIV with correct and complete information about how the virus is transmitted. When they have finished in South Africa, they may like to extend their investigation to other African countries.

[The Amnesty International report is discussed further in another blog post, October 10 2014]

Whites Only? Investigations Reveal Hospital Transmitted Hepatitis Infections In US


The satirical site The Onion ran the headline ‘Experts: Ebola Vaccine At Least 50 White People Away‘ at the end of July. I’m not citing this article because I think it is funny, but because it raises a shocking point very succinctly, one that must have passed through the minds of many over the past few months.

If such an outbreak were to become established in a wealthy country, mainly inhabited by white people, would it still be raging 9 months later? And what efforts would be made to establish the source of the infections?

There is probably no wealthy country precedent to compare with the sort of epidemics that are frequently found in poor countries, often without even attracting the notice of the western world (or not for very long). But a recent article published in the Mayo Clinic Proceedings outlines the kind of work that went into investigating the infection of 84 people with hepatitis C (HCV) and another 34 with bacterial infections in US hospitals over a 14 year period. In fact, the paper outlines a whole series of investigations, very impressive work, too.

Six healthcare personnel were identified as a result of these many, lengthy and thorough investigations. That’s an average of almost 20 patients infected for each worker. An estimated 30,000 patients were potentially exposed to blood-borne pathogens by these six people. Twenty three different hospitals were involved, in 10 different states. (Naturally, I don’t really know if the victims were all white people; the authors are far too polite to mention such detail.)

A 2009 article entitled ‘Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review‘, by Savanna Reid, estimates that 20 million medical injections contaminated with blood from a patient with HIV are administered every year in Africa. Other research by Yves Hutin, entitled ‘Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates‘, estimates that out of the 17 billion injections administered every year globally, 7 billion of them are unsafe.

So where are the HIV and hepatitis outbreak investigations carried out in African countries? They are not listed in PubMed, unless they are called something else, to throw investigators off the scent. Such an investigation was carried out in Pakistan in 2008, but as it confirmed the worst fears of those who believe that unsafe healthcare is a serious risk it appears to have attracted very little attention (and turned into what looks like a cover-up).

So what do we know about unsafe healthcare in African countries, in the absence of such investigations? We know that infants with HIV negative mothers were probably infected through unsafe healthcare in Mozambique, and some of the infants may have gone on to infect their mothers (though it hasn’t been seen fit to explain to these mothers how their infants may have been infected, nor even the likely source of their own infection).

We know that people who have received medical injections in Kenya and several other countries are several times more likely to be HIV positive than those who have not. We know that women who have sex only with other women in Namibia and other southern African countries have been infected and that their non-sexual risks have not been investigated. We know that many people found to be infected with HIV in most African countries have said they have not had sex, or that they have not had sex with a HIV positive person, or that they have only engaged in safe sex [earlier version corrected].

In fact, there are numerous instances of HIV outbreaks in African countries, and probably other diseases, which have very likely been caused by unsafe healthcare, reused syringes and other equipment, failure to comply with infection procedures, etc. But none of them have been investigated. Instead, there are vast quantities of data shoved into mathematical ‘models’, showing that HIV is almost always transmitted through heterosexual behavior in African countries (this being just one example).

Completely untrue, but in accordance with the ‘promiscuous African’ myth, which has a long history in the medical (and eugenics) literature. The authors of such papers systematically ignore empirical data and fail to investigate outbreaks, they assume that African people themselves are either seriously mistaken about their sexual history or just tell lies, and they go unchallenged by their fellow academics and even peer reviewers, who have the luxury of remaining anonymous, but seemingly prefer to toe the party line.

No doubt these mathematical models are great examples of academic prowess and rigor, that stand up to the highest levels of scrutiny. But they are no substitute for the kind of investigations that have been carried out into what is thought to be a mere tip of the iceberg in hospital transmitted hepatitis and bacterial infections in the US. However brilliant these models are in the field of epidemiology, they are the work of people who care nothing about their fellow human beings in African countries.

Why do these highly qualified academics care so little about poor black people and, apparently, so much about people more likely to be wealthy and white? Is it academic vanity, money, some kind of animalistic competitive instinct, or a combination of these? The challenge to all these clever academics, who can publish their work in the most prestigious journals and be cited in the cream of the western media, is to go to the same lengths investigating and stopping HIV (and ebola, HCV and other diseases) in African countries as they do in parts of the US before the epidemic spreads any further.

Revised History of HIV in Kenya – Part VII – Health Facilities


Part VI explored the possibility that family planning and Sexually Transmitted Infection (STI) services may have been provided in health facilities that would later be deemed unsafe in the context of HIV, involving reuse of syringes and other equipment with inadequate or no sterilization. Many determinants have been identified for STIs throughout the twentieth century, all over the world. They include poverty, poor education, unemployment, ‘promiscuity’ (Meheus, 1974), low prevalence of contraception and others. STI prevalence tended to be higher among men than women, high in both urban and rural areas, higher among unmarried than married people (Hopcraft, 1973) and fairly evenly distributed around a country such as Kenya. In contrast, HIV is more likely to be associated with relative wealth, better education, employment, proximity to roads and other infrastructure, higher use of contraception, urban dwelling, marriage and others. More women than men are infected, associations with sexual behavior considered unsafe are often not very strong and prevalence is unevenly distributed, with a few hotspots in Kenya and many ‘coldspots’. One might logically conclude that, while HIV can be transmitted sexually, it is often transmitted in other ways, and that is why patterns of infection for HIV differ so much from patterns of infection for other STIs.

However, there are important overlaps in these patterns of STI and HIV infection. For example, HIV prevalence was found to have reached 4% among Nairobi sex workers in 1981 and increased to 61% by 1985; this was established by retrospectively testing stored blood samples (Piot P, 1987). Females infected with non-HIV STIs in the past were generally found to be engaged in sex work or had a partner who had visited a sex worker. Prevalence of STIs was often high in certain occupational groups, such as transport workers, soldiers and those employed in extractive industries. As a result, these and other groups had long been targeted by STI eradication programs; sex workers had also been targeted by various family planning initiatives. This suggests that those facing high risks for infection with STIs, or assumed to face high risks, may have had increased non-sexual risk of being infected with HIV once that virus began to spread (having established itself several decades before). Although HIV prevalence went up to 81% among sex workers in Nairobi, it peaked in 1986 and declined steadily for nearly 20 years without any reasonable explanation being found for this trajectory (Kimani J, 2008). Oddly enough, neither Piot et al nor Kimani et al consider the very strong possibility that sex workers (and members of other targeted groups) were systematically infected with HIV through unsafe healthcare until this risk was eventually recognized (or perhaps changes in practices reduced the risk of transmission without anyone noticing the impact this was having on healthcare transmission until much later?).

In the early 80s, no precautions had been taken to prevent the transmission of blood-borne viruses such as HIV in health facilities, as the virus had only just been discovered. Throughout the 80s, as it became apparent that health facility transmission was (or could become) a significant risk, certain measures were taken to improve safety. But the changes would not have been adequate to eliminate transmission altogether. In the 90s, as mentioned in Part III, access to health facilities declined, which may have inadvertently protected many people from infection; HIV incidence in the general population peaked some time in the 90s, at a time when visitor numbers to health facilities would have been falling as a result of increasing poverty, the introduction of ‘user fees’, cuts in service provision and other factors. Sex workers and others thought to be ‘promiscuous’ must have faced a very high risk of being infected with HIV in STI and family planning facilities, although the risk must have decreased considerably some time in the 80s and continued to decline, without ever being completely eliminated.

As for those not considered to be so ‘promiscuous’, they would also have faced high risks in general health facilities. Family planning and STI facilities were often integrated into general healthcare services. Women attending antenatal care (ANC) services and giving birth may have faced higher risk than others (aside from sex workers and other groups targeted by STI and family planning programs). This makes it less surprising that very high HIV rates were found in ANC clinics from the late 80s onwards. HIV prevalence is often highest among women of childbearing age. While these same women may (or may not) be more sexually active that others among whom HIV prevalence is lower, they clearly face increased non-sexual risk of infection with HIV at ANC clinics that are not particularly safe. Family planning services were promoted widely, often aggressively promoted, and not just to those thought to be ‘promiscuous’. Family planning, ANC, contraception and even general health services tend to be more accessible and more utilized in urban areas, by wealthier, better educated people (Hopcraft, 1973), the very groups found to be more likely to be infected with HIV. So people with HIV are more likely to have faced various non-sexual risks, whatever about their sexual risks. Why do UNAIDS and the HIV industry seem only to consider their sexual risks? Piot et al and Kimani et al are not exceptional in completely ignoring the possibility of massive levels of healthcare transmission of HIV; the entire industry has grown out of denying that unsafe healthcare could have played a part in transmitting a virus that is a lot less efficiently transmitted through heterosexual sex.

For a long time in Kenya (and other developing countries), family planning had been seen as a means of ‘promoting economic development’, as well as ‘improving maternal and child health’. It wasn’t just highly intrusive and aggressively promoted because it was seen as beneficial to Kenyans and other Africans, but also because it was seen as a means of reducing population growth and averting an eventual global shortage of food, water and vital resources. In the same way that preventing and treating diseases in developing countries was a way of ensuring a ready supply of cheap labor in resource rich countries, family planning was seen as a way of controlling birth rates and population increases beyond what was needed for labor. For many NGOs operating in African countries now, family planning is development; and ‘maternal and child health’ consists of, pretty much, family planning. It is seen as something of a truism that maternal and child deaths can be reduced most readily by reducing fertility rather than, say, improving conditions in hospitals and elsewhere.

A 1973 paper reveals something about conditions in STI clinics in Uganda (Arya, 1973). For a start, it is pointed out that over 90% of the population lives in rural areas. Therefore, most of the population’s health needs are catered for by rural health centers, dispensaries and other minor facilities, staffed mainly by auxiliaries, rather than by more highly trained professionals. Whether it is because STIs were common or because the colonial and post-colonial administrations were exceptionally interested in them, Arya argues that “venereal disease played an important role in the organization of the medical services in Uganda in the beginning of this century.” Mulago Hospital, started in the second decade of the 20th century as an STI clinic, became and remains the largest referral hospital in the country. This is similar to Kenya, with specialist STI services being available in Mombasa and Nairobi for many decades. Health expenditure is low, estimated at around one dollar per year per person in the mid 70s, but basic health services were provided free of charge. Arya alludes to the lack of success of most STI programs, in both developing and rich countries, in bringing these diseases under control; he suggests that there are other diseases that may be in more urgent need of attention. Arya also notes that private practitioners provide STI services, mainly in larger towns, and that the quality of these services is unknown.

Arya published a paper in 1976 about the role of medical auxiliaries in STI control in developing countries (Arya & Bennett, 1976). In common with some other authors, Arya and colleague draw attention to the high disease burden faced by developing countries, coupled with the scarce resources, human, financial and material. These are particularly acute in rural areas, where most people live, but where well qualified professionals are reluctant to work. The authors also feel that STI services are mismanaged to the extent that they may be causing more problems than they are solving, with high prevalence resulting from “inadequate treatment, improper treatment or no treatment at all”. They mention high treatment default rates, find the contribution of private practitioners to STI control ‘questionable’ and conclude that the overall quality of services is poor. Diagnoses were unreliable (Burney, 1976), patients were receiving repeated injections of small doses of penicillin, which increased resistance, etc. Another paper notes the injection of large volumes of penicillin in some countries, which is likely to have involved the use of glass syringes and reusable needles in those days (Meheus, 1974). Contact tracing was generally beyond the capacity of STI service providers. Arya and Bennett recommend that medical auxiliaries specialize in STIs and that their training includes “knowledge of the local socio-cultural factors which largely determine traditional sexual mores” and note that STI patterns “differ from those in the western nations and may even vary from one area to another within a country”.

The papers cited above and in Part VI give a few insights into what things were like in terms of STI programs in Kenya and Uganda in the 1970s. Many of those said to be dying of ‘slim disease’ in Uganda in the early 1980s could have been infected with HIV as long as ten years before. If the rate of new infections peaked in the late 1980s, transmission would have been increasing throughout the 1970s, reaching its peak in the late 1970s. Why incidence peaked and then declined is another story. It may have had something to do with the 1978-1979 war with Tanzania (wars tend to be periods of low HIV transmission (Gisselquist, 2004)), the civil war from 1981-1986 or, much more likely, a combination of factors. Incidence began to increase a few years later in Kenya, perhaps in the mid 1970s, reaching a peak in the early 1990s, as discussed elsewhere. However, incidence started to increase earlier among certain groups, such as sex workers, transport workers and others who, significantly, had been targeted by STI eradication programs for decades. Incidence also would have peaked and begun to decline earlier in these groups.

Conditions in Kenyan health facilities in the 1970s, especially those providing STI and family planning services, were poor. If a blood-borne virus were to establish itself in one or more of these facilities, there would have been plenty of scope for it to be transmitted widely, not just among populations aggressively targeted by various health programs, but also among those requiring other health services, such as antenatal care. The risks of widespread transmission of HIV in health facilities were not recognized for a number of years and many more years had passed before any of these risks were addressed (some have yet to be addressed). But western HIV awareness campaigns were hijacked long ago by various parties who wished to present the virus as one transmitted almost entirely through ‘promiscuity’, and who wished to deny the possibility of transmission in health facilities. Because most of those infected in African countries were heterosexual, a different story about transmission needed to be created. Unfortunately, the same campaigns and strategies were exported from wealthy countries, where transmission was almost entirely a result of male to male sex or intravenous drug use. These campaigns were supremely unsuccessful in Kenya, but this was blamed on the failure of individuals to change their sexual behavior, rather than on any non-sexual mode of transmission.

If HIV transmission in health facilities and through other non-sexual modes continues, the virus will not be eradicated. More poignantly, if health facility transmission had been addressed in the 1980s, when it was realized that this was a very efficient mode of transmission, the virus would never have infected so many people. Some of the worst epidemics in the world only got going in the late 1980s or early 1990s, such as Zimbabwe, Botswana, South Africa, Swaziland, Mozambique and others. Many of the biggest players (bureaucrats, politicians, publicists, academics, industrialists, etc) currently driving the HIV industry have been in the business since the 1980s. Must Kenyans and other Africans wait till these ‘experts’ are gradually replaced by more enlightened personages? It is to be hoped that new generations of practitioners are not obliged to choose between adopting the deeply engrained institutional prejudices of their profession, or accepting the status of ‘dissident’ or ‘denialist’, unable to publish, teach or even present their views to the industry.

 

REFERENCES:

 

Arya, O. (1973). Changing patterns in the organization of the venereal diseases and treponematoses service in Uganda. Brit. J. vener. Dis, 134-138.

Arya, O., & Bennett, F. (1976). Role of the medical auxiliary in the control of sexually transmitted disease in a developing country. Brit. J. vener. Dis., 116-121.

Burney, P. (1976). Some aspects of sexually transmitted disease in Swaziland. Brit. J. vener. Dis., 412-414.

Gisselquist, D. (2004). Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa. SAHARA J., 114-27.

Hopcraft, M. V. (1973). Genital infections in developing countries: experience in a family planning clinic. Bulletin of the World Health Organization, 581-586.

Kimani J, K. R.-A. (2008). Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence. AIDS, 131-7.

Meheus, A. D. (1974). Prevalence of gonorrhoea in prostitutes in a Central African town. Brit. J. vener. Dis., 50-52.

Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.

Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.