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Borborygmus: Recent Contributions to HIV Epidemiology

Comments Off on Borborygmus: Recent Contributions to HIV Epidemiology Posted by on June 25, 2014

David Gisselquist has already written a critical reaction to Jacques Pepin’s latest attempt to rewrite the history of HIV and unsafe injections. But AidsMap has gone in the opposite direction, by writing a completely uncritical, triumphalist regurgitation of Pepin’s paper, without finding anything strange about this ‘study’.

It’s odd enough that Pepin’s findings happen to match earlier claims from him and others, some made quite a number of years ago, as if simply wishing away HIV transmission through syringe and needle reuse were enough to almost eradicate it completely.

But in the ten year period Pepin is dealing with, sexual transmission has received almost all the attention and funding; yet the contribution of sexual transmission must have increased if Pepin is correct. At the same time, non-sexual transmission, which has yet to be addressed, even acknowledged by the HIV hierarchy, has dropped by almost 90%, a truly etymological decimation.

Pepin’s estimations, the provenance of which are very unclear, fly in the face of data collected by the Kenya Aids Indicator Survey. A paper using data from this survey finds that men who have had one or more injection in the previous 12 months were three times more likely to be HIV positive and women were two and a half times more likely.

The minute number of HIV transmissions that Pepin estimates were a result of unsafe medical injections in a year globally, 17,000-34,000, could be closer to the number of HIV transmissions in Kenya alone that were transmitted through various non-sexual routes.

Vague proportions of HIV transmission through sexual and non-sexual modes are estimated using the thoroughly flawed Modes of Transmission Model, which is well criticized on this site. So it remains a mystery what Pepin is talking about. Kenya is unlikely to be the only country where unsafe healthcare contributes a substantial proportion of HIV transmissions; but it is one of the few countries in Africa that has carried out any research into this phenomenon.

AIDS, blood, HIV, iatrogenic, nosocomial , , , ,

UNAIDS’ Garbage In Garbage Out Strategy Found Fit For Purpose

1 Comment Posted by on June 24, 2014

Although a Journal of the International AIDS Society (JIAS) paper, which ostensibly analyses Modes of Transmission (MoT) data and reports, has been through some kind of peer review process, the term ‘systematic’ in the title is misleading. In fact the review is highly selective. The phenomena of HIV infection through unsafe healthcare, traditional and cosmetic practices have been left out completely. This is despite the ready availability of relevant and up to date papers about these phenomena.

The Don’t Get Stuck With HIV website is a repository for many relevant materials. David Gisselquist also made a paper available last year that they have completely ignored, entitled ‘UNAIDS’ Modes of Transmission Model Misinforms HIV Prevention Efforts in Africa’s Generalized Epidemics‘. The bibliography therein should be very useful for anyone who wishes to carry out a systematic review in the future.

The JIAS study mentions recommendations from a 2012 set of guidelines produced by an MoT ‘study group’ and one of them recommends to “Adopt a bottom-up approach, that is, an approach that ensures that sufficient data is available to parameterize the model before making changes to tailor the MOT to more finely represent the local setting”.

The fact that no data has ever been collected by MoT studies for non-sexual HIV transmission may explain why such modes of transmission are ignored by the JIAS study. But it doesn’t explain why non-sexual transmission receives so little attention in the HIV literature as a whole, aside from peremptory denial of its existence.

Gisselquist recently pointed out some of the most glaring flaws in the MoT methodology in a brief blog post. But even the JIAS paper itself unearths some remaining flaws that make one wonder why such a weak and fragile tool should still be used after about a decade of demonstrations of its uselessness.

Ironically, MoT tools were supposed to contribute to UNAIDS’ ‘Know Your Epidemic, Know Your Response’ strategy. This strategy, like all UNAIDS strategies, is based on the assumption that almost all HIV transmission in African countries is a result of heterosexual transmission. That means that the majority of people in high prevalence countries are said to be ‘at risk’, either of becoming infected or of infecting others. So every African HIV epidemic looks pretty much the same to UNAIDS because of the built in assumptions of their various ‘tools’.

Therefore, a strategy for ‘targeting’ those most at risk ends up not targeting anyone; HIV interventions must aim to cover entire populations. Aside from being a waste of money and time, as well as stigmatizing the most affected populations, UNAIDS have failed to account for the bulk of transmissions in high prevalence countries. The two decade old, phenomenally expensive institution throws up its hands and says that the majority of people at risk of being infected are people who fall into ‘low risk’ categories.

Despite scratching the surface of the Modes of Transmission Model and finding that that’s all there is to it, the JIAS paper concludes that some aspects of it need to be ‘revised’. Which is even more misleading than calling the paper a ‘systematic’ review. But if UNAIDS have achieved anything in the last two decades it is in showing that a garbage in garbage out strategy really does work, and may continue to attract funding for another 20 years, at least. I wonder how many of the authors of the paper will end up working for UNAIDS, if they haven’t already done so.

AIDS, blood, HIV, iatrogenic, nosocomial , , , , , ,

Prejudice Continues to Blind UNAIDS to Non-Sexual HIV Transmission

Comments Off on Prejudice Continues to Blind UNAIDS to Non-Sexual HIV Transmission Posted by on June 20, 2014

Perhaps the author means well by speculating about how much ‘sodomy’ there is in Zambian prisons. But articles like this miss a great opportunity to look at possible non-sexual HIV risks in prisons. For example, what are safety standards like in prison health facilities? Do prisoners engage in cosmetic practices, such as tattooing, piercing, even shaving and hairdressing? Do any of them engage in traditional practices that may involve skin piercing or cutting? Do any engage in blood oaths or anything else that could result in a HIV negative person coming into contact with the blood of a HIV positive person?

The article says that “homosexuality is among the six key drivers of the transmission of HIV in” Zambia. One source lists these drivers as: multiple and concurrent sexual partners, mother to child transmission, low and inconsistent condom use, vulnerable and marginalized groups, low rates of male circumcision and mobility and labour migration. Let’s look at each of them in turn.

No non-sexual ‘drivers’ are clearly identified there. But the list is a very weak tool for identifying the risks that many people face, given that prevalence reaches over 20% in the capital, Lusaka, and close to that figure in two other provinces. For example, several articles have shown that having multiple partners does not account for extremely high rates of HIV transmission; concurrent partnerships are no higher in high prevalence areas than in low prevelence areas, but they can not account for very high rates of transmission either, despite the frequent, triumphalist literature spewed out on the subject.

Many women are infected fairly late in their pregnancy or just after giving birth, when they are unlikely to have engaged in any kind of sexual behavior, let alone unsafe sexual behavior; and the partners of many women who seroconvert are HIV negative. In addition, some women are infected by their infant, who could only have been infected by some kind of non-sexual route, such as unsafe healthcare. We have no idea how common this phenomenon is.

HIV prevalence in many countries is higher among those who sometimes use condoms and lower among those who say they never do. Condom use only protects against sexual transmission of HIV, not against non-sexual transmission. The issue of circumcision is highly controversial and it has never been shown that the mass male circumcision programs currently being carried out in high HIV prevalence African countries will have any impact on HIV transmission, except by the use of dubious figures conjured up by those who believe that circumcision is superior to the alternative, which involves not slicing off a healthy piece of genital flesh.

Mobility and labor migration are perhaps more closely related to ‘vulnerable and marginalized groups’ in Zambia because HIV prevalence is exceptionally high among those involved in mining, for example. Many miners are mobile, many are immigrants, and high levels of HIV prevalence means that they are singled out for stigmatization by the HIV industry, which insists that HIV is almost always transmitted through unsafe sex. Therefore these high prevalence groups must be promiscuous, also careless, selfish, predatory and a whole lot of other pejorative things.

The HIV industry continues to stigmatize people who are often already marginalized, blame people who are infected and alienate people who are most vulnerable to suffering from poor health, facing many other hazards relating to health, poverty, education and employment. There are two ‘drivers’ of HIV epidemics, sexual and non-sexual. The industry concentrates on sexual transmission to the almost total exclusion of non-sexual transmission. This needs to be addressed if countries like Zambia are to reduce HIV transmission, especially in prisons and mining areas, and eventually eradicate it altogether.

[For more about non-sexually transmitted HIV through unsafe healthcare, cosmetic and traditional practices and how to protect yourself, visit the Don’t Get Stuck With HIV site.]

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Did Health Facility User Fees Cut HIV Transmission in 1980-90s Kenya?

Comments Off on Did Health Facility User Fees Cut HIV Transmission in 1980-90s Kenya? Posted by on June 19, 2014

Rick Rowden argues that the World Bank was negligent in imposing structural adjustment loans on very poor countries in Africa from the 1980s onwards. He notes that there was little or no evidence at the time that privatizing healthcare would be in any way beneficial in developing countries; on the contrary, the World Bank itself had warned against the introduction of user fees for healthcare in 1980.

After putting tens of millions of people through the disastrous consequences of these untried policies, there is now so much evidence of how damaging they are that even the World Bank agrees user fees are not a good thing. But they have not yet been held accountable, as Rowden argues they should be. Countless numbers of people have suffered and died, health services remain decimated in the worst affected countries to this day; is the World Bank going to try and put right the little that may still be salvaged from the wreckage?

Maybe those in the UK arguing for the imposition of user fees in the National Health Service (NHS) could peruse some of the copious amounts of evidence available showing that such a move will put the health and lives of the poorest and neediest people at risk, while making a handful of wealthy people even wealthier. They can’t use the excuse some would make for the ‘free’ market lunacy of the 1980s, that it was not known what the consequences would be.

But Rowden raises another tantalizing point. He cites one ‘H Stein’ as arguing that the exemption of some preventive services such as vaccinations from user fees, but not curative services, such as STI treatment, “led to the imposition of user fees in STD clinics in places like Kenya in the early 1990s. These fees lowered attendance rates at the worst possible time: the early stages of the HIV/AIDS epidemic in Africa.”

This argument is tantalizing because in the early 1990s HIV transmission among a large cohort of sex workers observed for 20 years had started to decline, and declined fourfold from the 1980s onwards. It is still not clear why HIV transmission declined in this group as members were selected precisely because they were engaging in ‘unsafe’ sex throughout the 20 year period.

Indeed, the national rate of transmission of HIV (incidence) peaked and started to decline in the early to mid 1990s in most parts of the country; it peaked and started to decline long before the government accepted there was a HIV epidemic in Kenya, even before any of the multitude of NGOs turned up to do whatever it is HIV prevention NGOs do (finger-wagging and other variations on that theme).

The authors of a paper on this cohort of sex workers started off their article assuming that HIV transmission is entirely down to sexual behavior. When sex workers who said they always used condoms were found to be HIV positive it was assumed they had ‘overestimated’ condom use. It was assumed that HIV prevalence was at a constant level of 30% among their male clients, although this is likely to be a far more telling overestimation. Other groups among whom HIV prevalence was found to be high were also assumed to have been infected solely through ‘unsafe’ sexual behavior.

It is surprising that risks for non-sexual transmission through, for example, unsafe healthcare (also traditional and cosmetic practices) were never considered for HIV positive people. Facilities were badly run, understaffed, undersupplied and, frankly, dangerous. STI clinics would have been more dangerous still. Why is it that only clients’ sexual risks were considered? Why is that still the case, more than 20 years later?

However, the introduction of user fees and the consequent massive drop in access to STI clinics and other health facilities could have given rise to the observed drop in HIV incidence in the 1990s, which continued into the 2000s. Non-sexual risks for HIV transmission, data for which was never collected, include treatment at an STI clinic, multiple injections, visits to an antenatal clinic, hospitalization, etc.

A 1987 paper by Peter Piot and colleagues finds very high HIV prevalence figures among sex workers, also among men attending STI clinics and women attending antenatal care clinics. But these three groups clearly face the abovementioned risks of being infected with various diseases in health facilities, especially those facilities that are on the brink of collapse; HIV is only one possible healthcare associated infection to which people could have been exposed.

Being a beneficiary of the admirable NHS, I would argue that the service should be further developed as a model for other countries to follow. That is especially true for African countries with very poor healthcare currently, but who, according to the economists who have so far failed miserably to get anything else right, are ‘rising’ economically, riding on a wave of buoyant economies and eye-watering potential for this to continue.

But striving towards universal primary health care is not enough. African countries need safe healthcare, not just any old healthcare. If healthcare access suddenly increases without improvements in safety and infection control, some of the currently declining epidemics may start to increase again. Botswana is an example of a country that decentralized its health services and ended up with one of the worst HIV epidemics in the world, one that is showing little sign of declining right now.

Given continuing high HIV prevalence in wealthier African countries with better access to health services and higher prevalence among wealthier people in urban areas, it is difficult to see Botswana’s experience as mere bad luck. If unsafe healthcare has been a factor in Africa’s worst HIV epidemics then this needs to be thoroughly investigated so that such avoidable transmission is addressed as a matter of urgency. Universal healthcare that is not also safe healthcare will only expose more people to more risks.

[For more about HIV transmission through unsafe healthcare and how to avoid it, see the Don’t Get Stuck With HIV website.]

AIDS, blood, HIV, iatrogenic, nosocomial , , , , , , ,

More junk science underestimating HIV from medical injections

1 Comment Posted by on June 16, 2014

AIDS experts still haven’t figured out what is different about Africa that can explain why HIV epidemics there are so much worse than elsewhere. The continuing failure to find what is different exposes persistent (intentional or natural) incompetence on the part of respected researchers.

Specifically, scores of studies that have tested, followed, and retested hundreds of thousands of HIV-negative Africans to find when and how they get HIV have failed to trace the source of observed new infections.[1] Without tracing the source, there is no way to say infections came from sex – but “HIV from sex” is nevertheless the conclusion (and racist slur) from decades of incompetent, incomplete research. When such studies find people with new HIV infections who report no possible sexual exposure to HIV, researchers characteristically reject the evidence: “hmmmm, an African with HIV…must have lied about sexual behavior….”

With that “scientific” method, the US National Institutes of Health and UK’s Medical Research Council could save money by paying researchers sitting in offices in Baltimore, US, or Oxford, UK, to make up data to fit pre-determined conclusions. That would be more efficient than paying them to go to Africa, collect data, and then reject what doesn’t fit desired conclusions.

While funders have avoided funding good science to explain Africa’s HIV epidemics – for 30 years and counting – they have been all too happy to fund junk science that will get the desired results. One popular junk-science strategy to get desired results has been to model Africa’s HIV epidemic with unreliable parameters and weak, selected, or made-up data.

The latest paper by Pepin and colleagues[2] falls into that category of junk science – presenting a model with unreliable parameters and data, and using results from the model to claim that unsafe medical injections accounted for less than 1% of new HIV infections in Africa in 2010 (8,000-16,000 from injections vs. 1.9 million total new infections[3]).

Several obvious problems with the estimate are as follows:

1. Pepin’s assumed rate of HIV transmission through a contaminated syringe or needle – 1 in 150-300 injections – is far too low to allow observed HIV outbreaks through health care in Russia, Romania, Libya, and elsewhere. If those outbreaks occurred – they did! – then Pepin’s proposed rate of HIV transmission through injections is misleadingly low. For example, in Russia in 1988-89 hospital procedures passed from HIV from 1 child to more than 260 children in 15 months. Most transmissions in this outbreak came from children who had been infected less than 6 weeks earlier – enough time for infected children to get dozens but not 150-300 skin-piercing procedures followed by reuse of unsterilized instruments.[4]

2. Pepin’s same model estimates 4,300-8,500 new hepatitis C virus (HCV) infections in Africa from unsafe injections in 2010, less than 1% of estimated new HCV infections (cf: an estimated 18 million Africans were living with HCV in 2005[5], which corresponds to approximately 1 million new infections per year). Because virtually all new HCV infections come from blood, not sex, it’s likely that unsafe injections account for a lot more than 1% of new HCV infections – and by extension, more than 1% of new HIV infections as well. Furthermore, other skin-piercing procedures aside from injections likely account for a lot of new HCV infections – and by extension a lot of new HIV infections as well.

3. Pepin’s estimates distract from facts that need answers. Why do 16%-31% of HIV-positive children in Mozambique, Swaziland, and Uganda, have HIV-negative mothers (among children with tested mothers)?[6] Why do so many mutually monogamous couples find that one or both partners are HIV-positive?

In his conclusion, Pepin commendably recognizes “other modes of iatrogenic transmission” including[2]: “use of multi-dose medication vials, phlebotomies with re-used needles, dental care with improper sterilisation of instruments, unscreened transfusions, ritual scarifications and circumcisions performed by traditional practitioners… Better measurement of such exposures and of their impact on viral dynamics is an essential first step…”

Even so, Pepin does not hit the nail on the head. What is required to measure the “impact [of such procedures] on viral dynamics” is to trace HIV infections to their source. When infections are traced a hospital, dental clinic, tattooist, etc, then continue with outbreak investigations to determine the extent of the damage from unsafe health care or other skin-piercing procedure.

References

1. Gisselquist. Randomized controlled trials for HIV/AIDS prevention in Africa: Untraced infections, unasked questions, and unreported data. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 14 June 2014).

2. Pepin et al. Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010. PLOS one 2014; 9: 1-8. Available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0099677 (accessed 14 June 2014).

3. Annex table 9 in: UNAIDS. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access, progress report 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241502986_eng.pdf?ua=1 (accessed 15 June 2014).

4. See: http://dontgetstuck.org/russia-cases-and-investigations/

5. Hanafiah et al. Global epidemiology of hepatitis C virus infection. Hepatitis 2013. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hep.26141/pdf (accessed 14 June 2014).

6. See pages for Mozambique, Swaziland, and Uganda at: http://dontgetstuck.org/cases-unexpected-hiv-infections/; see also: https://dontgetstuck.wordpress.com/cases-unexpected-hiv-infections/).

AIDS, blood, HIV, iatrogenic, nosocomial , , , , , , , , ,

HIV in Namibia: What You Don’t Seek, You Won’t Find

Comments Off on HIV in Namibia: What You Don’t Seek, You Won’t Find Posted by on June 13, 2014

There was no mention of HIV in Namibia’s 1992 Demographic and Health Survey and AIDS was only mentioned in passing. HIV prevalence had more than doubled since 1990, from 1.2% to 2.6%. But by 2000, when their second DHS was carried out, prevalence is estimated to have reached 14%, five times higher in less than a decade. So what areas of HIV had Namibia addressed during this time? The following table is from the 2000 DHS (p155, Table 11.1) :

Ways to avoid HIV/AIDS Women Men
Does not know AIDS or if it can be avoided 7.9 4.0
Believes no way to avoid 4.0 2.3
Does not know specific way 0.3 0.0
Abstain from sex 34.7 40.5
Use condoms 80.9 87.0
Have only one sexual partner 31.0 28.5
Avoid multiple partners 7.4 10.5
Avoid sex with prostitutes 1.0 3.3
Avoid sex with persons who have many partners 1.6 2.5
Avoid sex with homosexuals 0.2 0.3
Avoid blood transfusions 1.3 1.0
Avoid injections 0.8 0.6
Avoid sex with IV drug users 0.6 0.5
Avoid sharing razors/blades 2.2 2.6
Other including avoiding kissing/mosquito bites/traditional healer 1.8 1.6
Total 6,755 2,954

Aside from over 80% of people knowing about using condoms against HIV, which is good, knowledge about other ways of avoiding infection, even sexually transmitted HIV, ranges from poor to negligible. But the fact that less than 1% of people know that unsafe injections can transmit HIV is extremely worrying, considering risks from unsafe injections was well known at this time. More people are aware of the risk of transmission from razor blades than the risk of blood transfusions.

Even Jacques Pepin, who strenuously denies a significant role for unsafe healthcare in high HIV prevalence African countries, admits that 5% of HIV may have been transmitted via these routes globally in 2000, which means the contribution must have been far higher in countries with low safety standards and high HIV transmission rates, such as Namibia. Strangely, Pepin claims that safety in health facilities has improved so much in the ten years from 2000 to 2010 that “unsafe injections caused between 16,939 and 33,877 HIV infections” globally in 2010.

It is not very clear where Pepin got all his figures to carry out this estimate but there were an estimated 1.6m new HIV infections in sub-Saharan Africa in 2012 (compared to 2.6m in 2001). Does it seem credible that something in the region of 1.5% of all new infections globally (33,877 as a percentage of 2.3m new infections in UNAIDS’ 2013 Global Report), at the most, were transmitted through unsafe injections? It sounds like Pepin was trying to find a figure that concurs with UNAIDS’ Modes of Transmission Analyses, which have been claiming that the contribution of unsafe injections in African countries has been at that very low level since they started carrying out these analyses.

The Modes of Transmission model is so flawed that it overestimates heterosexual HIV transmission by several hundred percent, leaving the majority of transmissions unexplained. Therefore, their minute figure for transmission through reused syringes and other forms of unsafe healthcare could not possibly be correct, and seems to have been arrived at by overestimating heterosexual transmission and then claiming that only the remaining infections, a very small percentage, could be a result of unsafe healthcare.

Neither Pepin nor UNAIDS appear to have bothered investigating conditions in health facilities, possible outbreaks of healthcare transmitted HIV, infections among people who have never had sex, infections among people who only engage in ‘safe’ sex, infections in mothers who may have been infected by their infants and infections in infants whose mothers are HIV negative. If Pepin comes up with the same sort of figure as UNAIDS then his model is likely to be as flawed as theirs.

Namibia’s 2006-07 DHS finds that knowledge about ‘unsafe’ sex is high but this has had little impact on sexual behavior, nor on HIV transmission. So, no surprise there. The report blandly states that “HIV is transmitted among adults primarily through heterosexual contact between an infected partner and a non-infected partner” (which is what all DHS reports say, along with UNAIDS and other international institutions).

Report after report comes out on ‘knowledge, attitude and practices’ (KAP) from high prevalence country after country, and various well funded national and international institutions never seem to wonder if reducing HIV transmission is not merely about how much people know about sex, their attitudes towards sexual transmission and their sexual practices. For how long can this go on?

There’s a small amount of data in the 2006-07 DHS about whether people had medical injections and whether they remember if the person administering the injection saw the injecting equipment being taken out of a new packet, but there are no corresponding figures for HIV prevalence in relation to receipt of medical injections. It is concluded that most public and private facilities, at least 90%, practice safe injections, but that the lowest level of safe injections was found for women attending some types of private facility, at 49%; not so reassuring.

Figures for the next DHS (2013) are not yet available, but from the list of data being collected there doesn’t seem to be any new attention paid to non-sexual transmission of HIV, especially through injecting equipment reuse and other forms of unsafe healthcare. If you don’t investigate, you don’t need to deny finding the incriminating figures. This has worked for UNAIDS, but not for Namibia, or for any other country with serious HIV epidemics.

[For more about HIV from unsafe healthcare, visit our Healthcare Risks for HIV pages.]

AIDS, blood, HIV, iatrogenic, nosocomial , , , , ,

Namibia: Lack of Healthcare or Lack of Healthcare Safety?

Comments Off on Namibia: Lack of Healthcare or Lack of Healthcare Safety? Posted by on June 12, 2014

An online Namibian newspaper article reports that “Women who experience violence in volatile abusive relationships face four times higher risk of contracting HIV“, following a study of the links between gender based violence and HIV.

HIV prevalence is currently estimated at 13.4% in Namibia, an upper middle income country with a GDP per capita of $8,191, but also a high level of economic inequality. Population density is one of the lowest in sub-Saharan Africa.

However, when it comes to antenatal care, 81% of deliveries take place in a health facility. The only country I found in the region that was higher than that was South Africa, at 91.4%, which has the highest number of people living with HIV in the world.

81.5% of deliveries are performed by a skilled provider in Namibia. What is probably the highest figure in Africa is that for Botswana, at 99%. But Botswana has the second highest HIV prevalence in the world, at 25%, compared to swaziland’s 26%.

HIV prevalence is higher among women than men in Namibia, at 58% of all infections, and this phenomenon is common to every African country. While domestic and gender based violence need to be addressed regardless of how high or low HIV prevalence is, these are just as abhorrent in rich countries with low HIV prevalence as they are in an upper middle income country with high HIV prevalence.

According to the latest Service Provision Assessment, there are some very serious lapses in infection control in Namibian health facilities, including shortages or unavailability of syringes and needles, soap and water, latex gloves and disinfectant.

So what about addressing safety in health facilities? The number of physicians, nurses and midwives per 10,000 is higher than in other countries in Africa. Some of the biggest differences between Namibia and other much lower prevalence countries is its wealth and it’s far higher levels of access to health services. It is unlikely to be lack of healthcare that results in such high HIV prevalence, but rather lack of safe healthcare.

There is simply no evidence that HIV is ‘mainly driven by heterosexual sex’, the mantra that UNAIDS and the HIV industry have stuck to for so long. Prevalence in Namibia has increased from 1.2% in 1990 to reach a peak of at least 15.3% in 2007, but it has barely fallen since then. It’s time to abandon the sexual behavior fallacy and investigate non-sexual HIV transmission through unsafe healthcare, traditional and cosmetic practices.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don’t Get Stuck With HIV site’s Healthcare Risks for HIV pages.]

AIDS, blood, HIV, iatrogenic, nosocomial , , ,

Mass Male Circumcision: Cultural Imperialism and ‘Public Health’

2 Comments Posted by on June 11, 2014

“Three-quarters of women interviewed in Kenya’s highest prevalence province say they prefer circumcised partners” screams the headline. Except that only 30 women were interviewed.

There’s a whole rash of articles in praise of circumcision on the PLOS ONE site (Public Library of Science) that I simply don’t have the time or energy to read. Articles about how wonderful the operation is in reducing HIV transmission from females to males (not the other way, though) don’t appear to have found anything new in all the years they have been coming out. That is, aside from different ways of exaggerating the very small level of protection circumcision may afford men, other things being equal.

Women interviewed also believed, incorrectly, that circumcised men are ‘more hygienic and cleaner’. I wonder what would lead to them believing such a thing? Many people believe that a woman must wash herself after (and sometimes before) sex to be ‘more hygienic’, yet it has been known for some time that this is not only untrue, but that ‘vaginal douching’ increases the risk of infection with HIV. The same is true of male genital douching, but it was circumcision enthusiasts who established this, so they are not in a hurry to disabuse people of this dangerous myth.

It is hard not to see the push for circumcision, which comes almost entirely from the US, as highly stigmatizing and culturally imperialistic. It sounds as if men (and women), who in this instance belong to a non-circumcising tribe, are being told that Luo men are dirty because they are uncircumcised and that, since HIV is almost always transmitted through unsafe sexual behavior in Africa (a popular HIV industry myth), this ‘lack of hygiene’ is caused by not being circumcised. All they have to do is submit to circumcision and everything will be fine.

The branding of Luos as unclean and unhygienic by Western health practitioners is no less despicable than the views of other Kenyan tribes, who do practice circumcision, about Luos being ‘mere children’ and their leaders being ‘unfit to govern’ the country because they are uncircumcised. It is beliefs like this that have contributed to a lot of the ‘tribal’ violence Kenya has experienced, especially around election time. It seems the Western funded efforts to circumcise hundreds of thousands of Luos, perhaps millions, are not above using ‘tribalism’ to achieve their own ends.

Despite the small numbers, it is alarming that most of the women are said to express a ‘preference’ for circumcised men on the basis of beliefs that even the author accept are unproven: that circumcised men are ‘cleaner’ or ‘more hygienic’, that it takes them longer for them to ejaculate and that they ‘perform better’. Especially as the number who have ‘true’ beliefs, ones propagated by those promoting circumcision, is a lot smaller.

Is this kind of ‘demand creation’, based on complete lies, acceptable just because those doing the highly aggressive promotion claim that circumcision is effective at reducing HIV transmission from women to men (the absolute reduction being about 1.3%)? Or is it completely unacceptable, not because the reduction is very small, or because the randomized trials constantly referred to are highly suspect, but because this is a crude piece of cultural imperialism dressed up as a public health program?

AIDS, blood, HIV, iatrogenic, nosocomial , , , ,

HIV Transmission Via Unsafe Medical Injections in Kenya – Significant Risk

3 Comments Posted by on June 11, 2014

Congratulations to Kenya on being one of the first African countries with a serious HIV epidemic to investigate the role of unsafe healthcare and reuse of injecting equipment in transmitting HIV. The study finds that “Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months.”

But these findings make the conclusion of the article all the more striking: “Injection preference [my emphasis] may contribute to high rates of injections in Kenya.” If someone is infected with HIV as a result of receiving an injection, then it is the behavior of the health care practitioner that is at fault, not the ‘preference’ of the patient. Health facilities make more money from procedures such as injections than they do from just giving advice or handing out prescriptions, so there may be good reasons why patients ‘prefer’ injections; they may have been led to believe that injections are ‘better’. I’d also be surprised if mere patient preference made much difference to the kind of treatment a patient received in Kenya or elsewhere in East Africa.

Those providing health services need to take responsibility for healthcare associated HIV transmission, and that includes Ministries of Health, professional bodies, and also the WHO, UNAIDS, CDC and other parties who have dominated health and HIV policy in high HIV prevalence countries for decades. Reuse of syringes, needles and other skin piercing equipment carries a very high risk of transmission of HIV, hepatitis and other pathogens. It is not enough to blame patients for their ‘preferences’. Practitioners can decide what treatment a patient needs and what is the best means of administering it, if that means is available to them.

The paper recommends that “community- and facility-based injection safety strategies be integrated in disease prevention programs”. If this is UN-speak for the need to accept that HIV is frequently transmitted through unsafe healthcare and these practices need to stop, then I wholeheartedly agree. This is more than thirty years too late, but it’s good to hear the very mention of non-sexually transmitted HIV in the form of unsafe healthcare being taken seriously in a peer-reviewed journal. I look forward to hearing of other high HIV prevalence countries making the same ‘discovery’ and publicizing it, and also taking steps to reducing such transmission risks.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don’t Get Stuck With HIV site’s Healthcare Risks for HIV pages.]

AIDS, blood, HIV, iatrogenic, nosocomial , , , , ,

GlaxoSmithKline: “How Modern Clinical Trials are Carried Out”

Comments Off on GlaxoSmithKline: “How Modern Clinical Trials are Carried Out” Posted by on June 10, 2014

“We would need further details to investigate what actually took place, but the practices outlined certainly don’t reflect how modern clinical trials are carried out. We conduct our trials to the same high scientific and ethical standards, no matter where in the world they are run.”

That’s a comment from a GlaxoSmithKline spokesperson following the discovery of mass graves of an estimated 800 children in Ireland, who are thought to have died while taking part in ‘secret’ clinical trials, for which there is no evidence informed consent was ever given. That’s a huge number of deaths, by any standards. It is to be wondered how many deaths (and injuries) it took before the trials were stopped.

It would be nice to think that the GSK spokesperson is right, that such things could never happen today. But there’s a whole list of unethical practices in Wikipedia that GSK have been involved in, and those are just the more recent cases. And what about their current collaboration with the Gates Foundation to develop a malaria vaccine? Such a vaccine would be a godsend, but who is keeping an eye on them, given their record?

I don’t doubt that such things no longer happen in Ireland, nor in other Western countries. But unethical practices in African countries are certainly not a thing of the past.

The Don’t Get Stuck With HIV site has a section on DepoProvera (DMPA) hormonal contraceptive, which evidence suggests may increase infection with HIV among those using, and onward transmission by those using the method. Also on this site David Gisselquist has written about the unethical behavior of health professionals who have failed to investigate or act in any way on evidence that infants and adults may have been infected with HIV through unsafe healthcare.

WHO have been dragging their feet over unsafe healthcare, especially unsafe injections through reuse of injecting equipment, use of DepoProvera in HIV endemic countries and various non-sexual modes of HIV transmission. There are also the mass male circumcision campaigns, which are based on lies about research that was carried out in Kenya, South Africa and Uganda. It has never been explained how people who seroconverted during these trials were infected with HIV, it was just claimed that they must have had unsafe sex. Though many of the men did not have any obvious sexual risks, non-sexual risks were not considered, including the circumcision operation itself.

The list of serious ethical breeches goes on. Some participants taking part in the circumcision trials were not told they were infected with HIV, and were followed to see how long it would take for them to infect their partners, who also weren’t told they were at risk. This resembles the Tuskegee and Guatemala Syphilis ‘Experiments‘, which also ended in the 1960s. Yet mass male circumcision campaigns are ongoing and extremely well funded, despite not having anything like the rate of takeup anticipated by those making a lot of money from carrying out the operations.

There has been some secrecy surrounding DepoProvera, and a lot of data about mass male circumcision may have been collected but never released, but much of the data about these issues is readily available to anyone with an internet connection. Like the results of the Irish trials, much of the research was published in “prestigious medical journals”. But I assume this is not what GSK is referring to when they talk about ‘modern clinical trials’?

AIDS, blood, HIV, iatrogenic, nosocomial , , ,

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