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We do them in Black for 14.99

1 Comment Posted by on November 12, 2014

I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”

The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.

You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.

‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.

So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.

The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.

The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.

The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.

Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?

Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.

The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.

To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.

AIDS, circumcision, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

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

1 Comment Posted by on October 25, 2014

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.

AIDS, blood, circumcision, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

Revised History of HIV in Kenya – Part V – UNAIDS’ Rorschach Hypothesis

Comments Off on Revised History of HIV in Kenya – Part V – UNAIDS’ Rorschach Hypothesis Posted by on August 17, 2014

As I said in earlier posts, HIV arrived in Kenya and remained unnoticed until the 1980s. It is said to have spread rapidly throughout the 80s, especially in certain places (such as Nairobi, Mombasa, Nyanza province and perhaps a few others), but also to have remained low in other places (such as the North and Northeast). The rate of new infections, incidence, peaked in the early to mid 1990s and declined thereafter. So prevalence peaked in the late 90s or early 2000s, with high death rates, which may have peaked in the mid 2000s. The epidemic has a long early years tail (1950s-1980s), a humped back, possibly very humped, and a longish neck. Perhaps the curve resembles an outline of a diplodocus, complete with a little bump where the head should be, but just a small head.

With prevalence peaking at a little over 10%, but only for two or three years, the period of high transmission or incidence would have been six or seven years previously (going backwards again, for a moment). That suggests something catastrophic in the mid to late 1980s and early 1990s that was responsible for much of this rapid transmission. Whatever that something was, it didn’t result in rapid spread of HIV before the 1980s, and it ceased in the 1990s. It also ceased to result in rapid spread of HIV after a brief few years. Does that sound like sexual behavior to you? It does to the HIV industry, who have been trying to redescribe similar phenomena in all high HIV prevalence African countries.

So the diplodocus is not the only kind of epidemic curve; there are several dinosaur-like curves that you can spot using UNAIDS data. Many of them look very similar, but there are some whose backs rise two or three times higher than any of those found in East Africa, for example Zimbabwe. A few more countries show an epidemic that exploded in the 1990s but haven’t dropped yet, such as Swaziland and Lesotho. The Dinosaur is also a good metaphor for some of the institutions and international NGOs that have systematically resisted one of the best arguments for universal primary healthcare ever (HIV, that is), and continue to resist it to this day. HIV is almost all a matter of individual sexual behavior, they say.

But I did mention being drawn to spatial and temporal factors, rather than ‘populations’. Even in my first attempt at characterizing Kenya’s epidemic it was clear that there wasn’t really a ‘national’ epidemic. Instead, there were places where HIV prevalence was exceptionally high, and even more places where HIV prevalence was low. Over time, there were places, high and low prevalence, where the curves looked nothing like dinosaurs. They were more like pancakes in low prevalence areas, sometimes with a small piece of fruit under them, and Mexican hats in high prevalence areas. Could this data really describe sexual behavior over time? I was skeptical, not believing that almost all HIV could be sexually transmitted, as the HIV industry was claiming.

Then it was confirmed to me that HIV is frequently transmitted through unsafe healthcare, cosmetic and traditional practices, such as reused syringes and other equipment and practices in all three scenarios, with the second and third involving razors and other sharp objects that are used to pierce the skin, often the same ones over and over again, without any attempt at sterilization. Reasonable people were arguing that various kinds of bloodborne transmission were the only phenomena that could explain the Mexican hats. That accorded well with what I could glean from the literature. It just doesn’t accord with what the HIV industry insists: we know it’s all about sex, they insist, even when you present instances where it couldn’t possibly be.

I can give you about 50 reasons why I don’t believe HIV is entirely a matter of sexual behavior without even putting much thought into it (I’ve already written the list). But here are 10, with supporting links, so you can follow them up if you are interested. I’ll supply more in Part VI, perhaps even the rest, I’m not sure yet. Many of the reasons I give overlap with the factors involved in HIV transmission that I listed in Part IV, so if you wondered about any of them, you’ll probably be able to match the two lists, eventually. I may even merge them some time, but not now.

1 Prevalence is often higher among rich people. Consult the Demographic and Health Survey (DHS) for most African countries with serious HIV epidemics and you’ll find this. There is a table of HIV prevalence by wealth quintile that I drew up and it is available on a linked blog post I wrote recently.

2 Prevalence is often higher among better educated people. Again, the DHS gives data on this for all high HIV prevalence countries, but here’s a graph with some of the data in a table.

Education focus countries

3 High prevalence often clusters around transport infrastructure. Here’s a wonderful map of Africa where you can see why there are the several HIV regions I mentioned in an earlier part. But notice that ‘spatial accessibility’ or ‘friction’ that they mention do not explain all the regions. West Africa has a less serious epidemic than both East and southern Africa, yet there is good transport infrastructure there.

4 High prevalence often clusters around big employers, such as mines, plantations, etc. But miners and those employed in large numbers face other threats, such as employer supplied healthcare, public health programs, tests, checkups, STI programs and whatever else. Some may face additional sexual risks when they spend 11 months of the year in an all male hostel, but anyone who thinks that this sub-human treatment only impacts on victims’ sexual behavior needs psychiatric assessment.

5 Prevalence is usually higher in urban areas (where non-sexual risks are also higher). But there are multiple differences between urban and rural areas, only some of which relate to sexual behavior. The HIV industry loves going on about ‘sexual networks’, and not just in African countries. But what about the appalling conditions most urban dwelling people experience when they are born in a city or when they move to one? Slums are dangerous places, where children die of water borne diseases that cost a few cents to cure because what they need is clean water, to ensure they don’t get any of a multitude of waterborne diseases. Babies and children die of pneumonia and various respiratory problems, again, easily avoided and treated. But even if you pump a child full of available vaccines and send them back to the same environment, many of them will just die of something else. Adults die of all kinds of things as well, often as a result of the terrible living conditions. Many die or are disabled by road traffic accidents and other kinds of serious injury. Slums, where about 75-80% of Kenya’s urban dwellers live, are dangerous. Does anyone who has thought about it really think the only risks they face are sexual?

6 Prevalence is usually lower in rural areas (where non-sexual risks are also lower; have a look at any DHS). This is not to say that people don’t face hazards. They also don’t receive the benefits of public health programs that are available to people in the cities. Of course, this can protect them from healthcare associated HIV and other diseases but many vaccines work well, a lot of common diseases can be prevented or cured. However, when it comes to HIV, rural dwellers seem to be a lot better off, and inaccessibility of healthcare facilities may have protected them, at least in the recent past. My guess is that while some may be involved in ‘sexual networks’, just as people all over the world are, these do not explain everything.

7 HIV prevalence is not particularly closely related to ‘unsafe’ sexual behavior. For example, DHS figures for sexual behavior among young people in Zimbabwe show how tenuous the connection is. Even the authors were unable to interpret them. But a careful look at sexual behavior figures for many countries show that the numbers engaging in these behaviors tend to be a lot smaller than the numbers not engaging in them. These levels of ‘unsafe’ sexual behavior would not be able to explain the Mexican hat graphs in Nyanza and in Kenya’s major cities.

8 Prevalence is often lower among those who never use condoms. As the linked article shows, condom use is often associated with higher rates of transmission than non use. The authors try to imagine arguments to show why condoms look like they are failing more often than not, but they don’t come up with anything convincing. The figures in the article have been superseded and there’s a more up to date table in a blog a wrote a short time ago. My guess is that condom use is higher among urban dwelling, better educated, wealthier, employed people, and that’s why you get these same patterns for condom use in so many countries. Again, this strongly suggests that HIV is not purely a matter of sexual behavior.

9 HIV prevalence is low in areas where ‘intergenerational’ marriage and sex, that is, between people of very different ages, are more common. I’m linking to a blog post I wrote recently, no point in repeating the whole thing again. The data is from DHS for various countries.

10 HIV prevalence is low in areas where ‘traditional’ practices are more common, such as traditional medicine. These tend to be more common in rural and isolated areas. A possible exception to this is genital mutilation. There are two kinds, only one of which is ‘traditional’. The first kind takes place in a health facility, so that’s usually male genital mutilation. The second kind does not take place in a health facility and includes male and female genital mutilation. It’s hard to say which is more likely to transmit HIV. If mass male circumcision was being carried out in a health facility where infection control procedures were not followed properly, not an uncommon occurrence, then healthcare associated transmission could be very likely, and would be serious; some practitioners are carrying out twenty operations a day, apparently. Traditional circumcision, which has its own hazards, is carried out in entirely unsterile conditions and adverse events are common. But it may be less likely that a HIV positive person is being circumcised along with other initiates. Prevalence should be low among young uncircumcised males. Even if they engage in sex before the wound has healed, those with whom they have sex should also be less likely to be infected. But whether done in a clinic or in a field, genital mutilation is risky. Female genital mutilation generally takes place in unsterile conditions and the risks of some forms may be higher than those faced by males. But female genital mutilation is also more likely to take place in rural areas, where HIV prevalence is lower. It is said that almost 100% of Ethnic Somalis in Kenya’s Northeastern province, both male and female, are genitally mutilated, but HIV prevalence is very low.

HIV probably did very little for years in Kenya. But next to nothing for years is the way to go from being a species jump that should never have survived to being a pandemic. Perhaps a clearer history of how it survived and spread, to explode in the late 80s or early 90s, will tell us more about what is still driving transmission, in Kenya and elsewhere. But there are already many reasons for believing that HIV is not only transmitted through sex. One would want to be seriously disturbed to interpret every factor involved as evidence of sexual behavior.

AIDS, blood, circumcision, ebola, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, VMMC , , , , , , , , , , , , , , , , , , ,

Revised History of HIV in Kenya – Part IV – Diversity

1 Comment Posted by on August 14, 2014

Why is HIV spread so unevenly? In some parts of Kenya prevalence is at ‘hyperendemic’ levels, over 20%, almost 30% in one county. Yet in other counties it is low, 1% or lower. If, as we are constantly told, 80%, even 90% of HIV transmission is a result of unsafe sex (most of the remaining 10-20% being a result of mother to child transmission), what amazing sex lives people in some counties must have (or disgraceful, if you prefer). And what dull (or worthy) lives those in other counties must have, apparently only having sex for the purpose of procreation.

If, on the other hand, HIV is not always a result of sexual behavior, if many people may be infected through unsafe healthcare, even unsafe cosmetic and certain traditional practices, some of the factors involved in HIV transmission rates, low or high, start to make a lot more sense. The list of factors is long (over 40), but the italicized paragraphs are the kind of explanations given by the ‘it’s all about sex’ camp, so they are mostly the same. Yes, some HIV transmission is a result of sexual behavior, nobody is denying that, but some is not. Also, some areas where HIV transmission is high are in need of further study; a priori explanations for high and low prevalence have no place in science (though they seem to receive a warm welcome in a lot of papers on HIV epidemiology).

Christian

Prevalence is often higher among Christians than Muslims, and generally among males than females; not sure why this is so; the majority of HIV positive people in the world live in predominantly Christian countries, meaning that a lot more Christians than non-Christians are infected; why this is so is not clear, although both healthcare access and HIV prevalence are noticeably low in some Muslim dominated countries

Men less likely to be circumcised; also Christians are ‘less restrained’ in their sexual behavior than Muslims

Circumcision

There is no clear evidence that circumcision reduces HIV transmission and it could only influence sexual transmission, at best; however circumcision is risky if carried out in unsafe healthcare facilities or in traditional settings

Circumcision ‘cleaner’ or ‘more hygienic’, although this is a hypothesis, there is no unambiguous evidence

Colonization

The vast majority of HIV positive people live in countries that were colonized by the British. This may relate to healthcare facilities, access to healthcare, health seeking behavior, infrastructure, stability, etc

It’s somehow related to sex

Condom use

HIV prevalence is higher, often far higher, among people who sometimes use condoms than among those who never do, suggesting that HIV risk is not always sexual

Those who are already infected are more likely to use condoms

Culture

Cultural practices such as female genital mutilation (FGM) may increase the risk of being infected, although it increases both sexual and non-sexual risks; yet prevalence among people who practice FGM is generally low, which suggests that there are other factors involved

Increases HIV transmission; if prevalence is low this can be explained away by reference to attitudes towards extra-marital sex, etc

Depo Provera

Increased risk for women taking it and for their partners

Denies that this is a risk and claims that the benefits (prevent conception) outweigh any disbenefits, which don’t exist anyway

Education

Educated people may have better access to healthcare and be more likely to use healthcare

Educated people have access to bigger sexual networks

Employment status

People with a job can afford healthcare, although this may not be safe healthcare; jobs may include healthcare or health insurance; some occupations provide healthcare services;

People with a job have more money and therefore access to bigger sexual networks; despite prevalence generally being higher among employed people, some suggest that unemployed people have little else to do but have sex

Female

Prevalence is usually higher among women, possibly because they have more need to use healthcare services, especially when pregnant and giving birth; they are also more susceptible to sexual transmission

Women are more vulnerable and have less power to make choices; they are usually victims, otherwise they fall under one of the many categories of sex worker

Fertility

Higher fertility may increase healthcare exposure, although it is often associated with low prevalence areas, rural areas, etc

Higher fertility means more unprotected sex

Healthcare

Healthcare may not always be safe, which may explain why countries with good access to healthcare for everyone, such as Botswana, may result in higher HIV prevalence

Sick people, including people with HIV, seek healthcare, which is why healthcare may seem to be associated with higher HIV prevalence; this is especially true of STIs

Hepatitis

HBV and HCV are much more likely to be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices, also injection drug use

Presence of HBV and/or HCV are signs that the person is either promiscuous or an intravenous drug user (or both)

Herpes

Rates can be extremely high in some populations because it is very easy to transmit, sexually and through other routes; it plays a role in being infected with and transmitting HIV but the role is complex

It is a sign that people infected engage in unsafe sex and increases risk of transmitting and being infected with HIV

Inequality

It is neither clear that inequality is associated with higher risk, nor why this may be so

People are more vulnerable to sexual risk, especially women

Infrastructure

Good infrastructure is often associated with high HIV prevalence, which may suggest better access to unsafe healthcare

Good infrastructure gives access to bigger sexual networks

Male

Prevalence is usually lower among men than women, which leaves a question mark over instances of higher prevalence among men when they are found, for example, Muslim men in Kenya; prevalence may be lower because of lower use of health facilities

Men are considered to be mere spreaders of sexually transmitted disease, whether they are rich or poor, urban or rural dwelling, etc

Marriage

Sometimes HIV prevalence is far higher among married than unmarried people and it is not clear why

Married people are less likely to use condoms; they also have extra marital sex, usually the men, then they go home and infect their spouse

Migration

Migration can be for work, which may involve work-related healthcare, which may be unsafe and may not be subject to levels of scrutiny faced by public facilities, however scrutinized  they may be

Migrants, being away from home, either have other sexual partners or visit sex workers; they then return home to infect their spouse

Mobility

Possibly increases access to health facilities, but mobility on it’s own doesn’t seem to explain high prevalence

Mobile people have access to bigger sexual networks

Muslim

Figures vary, with prevalence higher among Muslims than Christians in some countries (eg, Burundi, Rwanda, Mozambique, but not Kenya or Tanzania), also higher among Muslim men than women in others, eg Kenya; not sure why this is so

Men more likely to be circumcised; also Muslims are ‘more restrained’ in their sexual behavior than Christians

National borders

High HIV prevalence has been reported at border areas in the past and rates of unsafe sexual behavior may be higher; but the sex workers and long distance drivers who are said to be responsible for high rates have often taken part in STI eradication programs and may frequently use STI clinics

Long distance drivers have sex with sex workers, then they go home and have sex with their spouses

Occupation – armed forces

Members are unlikely to have any option as to whether they take part in various health programs, tests, etc; healthcare is likely to be free, which means usage is also probably higher

They have access to bigger sexual networks and frequently visit sex workers

Occupation – fishing

Prevalence is high in fishing communities, not necessarily highest among the fishermen; also, very high prevalence seems to be a feature of only some fishing communities, especially lakes; not sure why HIV prevalence is so high

Fishermen do risky work, therefore they are not bothered by sexual risk; also, they spend a lot of time away from home; also, they use sex as a bargaining tool

Occupation – mining

Artisanal mining is not so much associated with HIV so this probably applies to industrial scale mining; the work-related healthcare to which miners have access (they may even be compelled to receive certain health services and tests) may not be safe

Miners work a long way from home and don’t see their family much so they have extra-marital relationships and/or visit sex workers, then go home and infect their spouses

Occupation – teaching

Prevalence has been claimed to be higher and lower among teachers, at different times and places; they probably face similar risks to other public sector employees, whatever those may be

Teachers frequently have sex with their pupils (which may be true, and should be addressed, but it may turn out to have little to do with HIV transmission)

Occupation – transport

Transport workers may use health facilities more; also, they may have been persuaded to take part in STI eradication programs as they have been blamed for all sorts of things; these STI programs may not always have been safe

Transport workers are mobile, which means they have access to bigger sexual networks; then they go home and infect their spouses

Polygamy

Sometimes associated with higher transmission, sometimes with lower transmission, therefore not clear. It is not only practiced by Muslims but also by some tribes and even at least one Christian sect in Kenya

When prevalence is higher, this is because polygamy involves ‘concurrency’; when lower, it’s because men with more than one wife don’t need to have extra-marital sex, or not as much

Population density

Increases pressure on health facilities

Said to increase the size of sexual networks

Population growth

Increases pressure on health facilities

Said to increase the size of sexual networks

Poverty

HIV prevalence is often lower among poorer people, suggesting that they may face lower risk from, for example, unsafe healthcare because of reduced access; however, being poorer means that the only healthcare available may be unsafe

If prevalence is high, poorer women are more vulnerable (to sexual transmission) for various reasons;  if it’s lower, poorer people are less likely to be part of a ‘sexual network’ or their networks are likely to be smaller

Prisoners

There may be some kind of drug use that involves cutting or skin piercing (seems unlikely injection drug use would be common); healthcare is unlikely to be very comprehensive or safe; tattooing and traditional medicine may be additional risks, perhaps also scarification, blood oaths, etc

They have sex with other prisoners, the implication being that the sex includes anal sex; and/or injected drugs or drugs that involve skin piercing; condoms are usually not permitted

Rural

Rural dwelling people have less access to health facilities and infrastructure, which may go some way to explaining why prevalence is usually lower in rural areas

Rural dwelling people have access to smaller sexual networks

Schistosomiasis

This has been shown to increase susceptibility to infection and onward infection, which suggests that some people have sex, not very surprising; but endemic schistosomiasis, which is very cheap to treat, suggests weak healthcare systems

Lots of people having lots of sex with lots of other people all the time: schistosomiasis only adds to what is a ‘known issue’

Sex work

Prevalence among sex workers is low among some sex workers in Western countries unless they also engage in injection drug use but their biggest risk in countries with unsafe healthcare could be their frequent exposure to STI clinics and STI eradication programs; also, a lot of what is referred to as ‘sex work’ is in fact sex between people who are in a relationship or married; many people who are related, in a relationship or married also do business with their partner or relative; ‘gift giving’ is sometimes said to be a form of ‘transaction’ between two people who have sex; this is a very stigmatizing use of the term ‘sex work’ (a bit like the term ‘orphan’, which refers to children in developed countries who have lost both parents, but children who have lost one parent in developing countries; or the word ‘trafficking’ which seems to refer to just about anything that involves sex and that can attract funding to ‘rescue victims’ from)

Sex workers are forced into sex work by poverty, powerlessness, vulnerability, etc, but their consequent risks are high and entirely sexual, unless they are also injection drug users

STIs

STIs do not only suggest unsafe sexual behavior, they also suggest a health system that is failing; some are also transmitted through non-sexual routes, such as herpes and HIV

STIs are a sign that a person engages in unsafe sex

TB

TB is likely to be an occupational disease in deep mines, though mining operations deny this, as they don’t want to compensate those who contract it, pay for their treatment or improve conditions in mines; it increases HIV transmission in both directions

HIV positive people are more susceptible to TB

Tribe

Prevalence is high in some tribes and low in others (high among Luos, low among Somalis in Kenya, for example), which suggests that there may be several factors involved; there are ‘risky’ practices in tribal groups among whom HIV prevalence is low, as well as high (for example, female genital mutilation, which is widespread among Somalis)

‘Tribal’ practices and/or ‘traditional’ practices can be wheeled out on any occasion, either to explain high prevalence or low prevalence; they often involve sex or some form of brutality an are generally inflicted by men on women

Urban

Urban dwelling people have easier access to health facilities and other infrastructure

Urban dwelling people have access to bigger sexual networks

War/civil conflict/refugee camps

Prevalence is generally low during wars and only increases after the war has finished, perhaps because health seeking behavior changes during wars, health facilities become less accessible, money is short, infrastructure is destroyed, etc

If HIV is transmitted it is because people take advantage of the situation, rape and other forms of sexual violence being common; but as prevalence is usually lower it is claimed that sexual networks become smaller, people return to rural areas, etc

Wealth

Prevalence is often higher among wealthier people, suggesting that they may use healthcare more frequently; they may also face occupation related risks that are also non-sexual

Wealthy people can become part of larger sexual networks; they have more opportunities for sex and are more likely to avail of these opportunities

Widowhood

Prevalence among widows and widowers can be very high but it is not clear why

Widows are, in some cultures, inherited, having been widowed because their husband (obviously) died of AIDS; they are ‘cleansed’ (have sex with their inheritor) who may be the brother of the deceased, and infect him; he goes on to infect his other partners, including his spouse

The list above makes no claim to be exhaustive. When there is so much diversity in HIV epidemics within and between countries, why would anyone conclude that almost every factor is, ultimately, a matter of sexual behavior, or somehow relates to sexual transmission? It’s no wonder, given the above list, that HIV positive people are feared, even despised. It is the view that transmission is almost always sexual that results in the stigma UNAIDS and other institutions claim to abhor and pretend to be fighting; they are the source of the stigma. HIV ‘prevention’ programs that include some or all of the italicized arguments above merely spread the stigma.

AIDS, blood, ebola, FGM, HIV, iatrogenic, MGM, VMMC , , , , , , , , , , , , , , , , , , ,

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

Comments Off on Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics Posted by on July 30, 2014

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else’s blood, or how to avoid this.

The Don’t Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else’s blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don’t Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don’t know there is a risk and they don’t know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO’s ‘Tool C’, also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

“Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface…

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub…

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections…

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle…

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes…

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container.”

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and ‘traditional’ practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.

AIDS, blood, circumcision, ebola, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

Why ‘Reducing HIV Transmission’ Must Never be an Excuse for Genital Mutilation

2 Comments Posted by on July 24, 2014

The English Guardian has put together figures for female genital mutilation (FGM) and the top ten are Somalia, Guinea, Djibouti, Egypt, Sierra Leone, Mali, Sudan, Eritrea, Gambia and Burkina Faso. But the top ten for HIV that I have been looking at recently are Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Zambia, Namibia, Mozambique, Malawi and Uganda. The table below shows just how dramatic the non-correlation is.

FGM and HIV

The English Guardian is calling for an end to FGM, of course, not for it to be used to reduce HIV transmission. But a far less dramatic non-correlation has been used to justify three randomized controlled trials of mass male circumcision in African countries. The results of these trials have been used to justify a continuation of mass male circumcision, supposedly to reduce HIV transmission, involving tens, even hundreds of millions of men, boys and infants, and several billions of dollars. While HIV prevalence is lower among uncircumcised men than circumcised men in some countries, it is lower among uncircumcised men in others, while in several more countries circumcision status makes no difference. The correlation coefficient is roughly zero.

Results of further research into mass male circumcision is being presented to 16,000 attendees at the Melbourne HIV conference this week, research carried out on people who are not aware that they are guinea pigs for the current obsession with the operation. Because, as the figures show, we have no idea why circumcision sometimes appears to ‘protect’ against HIV and why it sometimes appears not to. Nor do we have any idea what proportion of HIV is transmitted through sexual contact and what proportion is transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

Similarly, we have no idea why HIV prevalence is so high in some African countries but so low in others. The fact that HIV prevalence is very low in countries that practice FGM is not seen as justification for carrying out trials of the operation on millions of people and presenting the results at an international HIV conference (such trials would probably be carried in secret, anyhow). In fact, FGM status is quite rightly seen as irrelevant to HIV transmission, and that even if it is somehow relevant, carrying out trials into the operation as a HIV intervention would be entirely unethical.

International health and development institutions, the UN, the mainstream media, political and religious leaders all around the world, and many others, condemn FGM and would not consider it as a means of reducing HIV transmission. They would not even condone carrying out field trials into any kind of FGM, not even the less damaging kinds of FGM, the kind that does no permanent damage, because it is not ethically justifiable to carry out such an operation for no medical reason on infants, children, or even unconsenting adults.

But the research carried out by the people slapping each other on the back in Melbourne, presumably at some considerable cost, were financed by the likes of the Gates Foundation (which also funds the English Guardian’s Development section, where the FGM article appears), FHI 360, Engender-Health and University of Illinois at Chicago. Several (if not all) of these institutions have their origins in a ‘population control’ theory of development, the belief that the population of developing countries is too high, and lowering birth rates will increase development and reduce poverty; less polite people would call this ‘eugenics’.

I wonder if these parties have some information about, or beliefs about, mass male circumcision having some negative influence on fertility. Because, if they were to believe the same thing about FGM, would they also promote it with the same energy and persistence (and funding, and institutional backing)? What about other means of reducing fertility, such as Depo Provera, which has been associated with higher rates of HIV transmission? Gates and other ‘population control’ organizations certainly do promote that.

So promoting your favorite ‘public health’ intervention as a means of reducing HIV when the evidence is slim is bad enough. But this intervention involves something that is ethically unjustifiable unless it is carried out for medical reasons. So these various parties went a step further: they carried out, and continue to carry out, ‘trials’ of this operation on millions of people. The excuse is that it ‘reduces HIV transmission’. But using that kind of evidence, so does FGM.

Genital mutilation without consent is not ethically justifiable; the fact that HIV prevalence is lower in countries where genital mutilation is common does not justify mass male circumcision programs, where millions of people are unwitting guinea pigs to this neoeugenicist experiment. Those promoting mass male circumcision programs, funding them or working on them are involved in a crime of inestimable proportions, and must be stopped.

AIDS, blood, circumcision, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial