Bloodborne HIV: Don't Get Stuck!

Protect yourself from bloodborne HIV during healthcare and cosmetic services

Category Archives: HIV

Stigmatize or prevent?


As a US citizen, my tax dollars promote the lie that almost all HIV infections in adolescents and adults in Africa come from sex. Experts who should know better began this lie in the 1980s and have repeated it for decades. The lie ignores early[1] and recent[2] evidence that only a minority of infections come from sex. Most who repeat the lie intend no damage because they believe it.

Whether a deliberate lie or repeated by those who don’t know better, the lie stigmatizes and hurts HIV-positive people. For example:

Beginning in 2015, USAID’s DREAMS program in 10 African countries proposed to reduce new HIV infections in women aged 15-24 years by 40%. DREAMS focused exclusively on sexual risks.[3] By ignoring bloodborne risks, the DREAMS program stigmatized HIV positive women, implying their infections came from sexual behavior, and implicitly charged infected virgins with lying: you’re a slut and a liar. Many young HIV-positive women in the 10 DREAMS countries are self-reported virgins. Since only a small minority of infections in young women in Africa come from sex[4], DREAMS was ill-designed to protect them: predictably, an assessment of Dreams’ impact in South Africa, looking at almost 2,000 women, found that exposure to DREAMS’ programs “was not associated with measurable reductions in risk of sexually acquiring or transmitting HIV.”[5]

WHO in 2012[6]  recommended “Couples and partners should be offered voluntary HIV testing and counselling with support for mutual disclosure.” The document recommended counseling couples about sexual risks but not bloodborne risks. Silence about bloodborne risks encouraged HIV-negative spouses to suspect their infected partners got HIV from sex. Such suspicions threatened relationships and families.

WHO in 2016[7] recommended: “Voluntary assisted partner notification services should be offered as part of a comprehensive package of testing and care offered to people with HIV.” As in 2012, WHO in 2016 recommended counseling couples about sexual risks but said nothing about bloodborne risks. As noted above, silence about bloodborne risks threatened relationships and families. 

WOMENKIND Worldwide defines sexual bullying to include (page 3 in reference [8]) “…spreading rumours about someone’s sexuality or sexual experiences they have had or not had…” The lie that almost all HIV comes from sex promotes such bullying, encouraging people to suspect and spread rumours about the sexual behavior of HIV-positive adolescents and adults in their families and communities.

Not preventing HIV

Warning only about sex risks not only stigmatizes HIV-positive adolescents and adults, it also undermines HIV prevention by encouraging HIV-negative people to ignore avoidable skin-piercing risks. The DREAMS program, for example, by focuses young women’s attention on sex encourages them to overlook bloodborne risks, which are their bigger risk (see Table 6.1, Figure 6.3, and associated text in reference [4]) Messages that warn about both risks would give people the information they need to avoid HIV.

References

1. Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161.

2. Gisselquist D. Recognizing and stopping blood-borne HIV. SSRN [internet] 2022. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4174723 (accessed 23 January 2023).

3. Saul J, Bachman G, Allen S, et al. The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women. PLOS ONE, 7 December 2018. Available at https://doi.org/10.1371/journal.pone.0208167 (accessed 22 January 2023).

4. Gisselquist D. Stopping bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available at: https://sites.google.com/site/davidgisselquist/chpt6sbh (accessed 24 January 2023).

5. Nondumisoa M. Kathya B, Natsayia C, et al. The association of exposure to DREAMS on sexually acquiring or transmitting HIV amongst adolescent girls and young women living in rural South Africa. AIDS 2022; 36: S39-S49.  Available at: https://journals.lww.com/aidsonline/Fulltext/2022/06151/The_association_of_exposure_to_DREAMS_on_sexually.5.aspx (accessed 22 January 2023.

6. WHO. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. Geneva: WHO, 2012. Available at: #14 COUPLES HIV TESTING AND COUNSELLING (who.int) (accessed 13 January 2023).

7. WHO. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: WHO, 2016. Available at: https://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf (accessed 22 January 2023).

8. WOMANKIND Worldwide. Stop sexual bullying: preventing violence, promoting equality, act now. London: WOMANKIND Worldwide, 2010.

After investigating unexplained infections, what’s left for HIV prevention research?


Here’s a proposal: Manage prevention research to prevent HIV

Design and manage HIV prevention research to prevent new HIV infections in participants. At the outset:

Warn participants about bloodborne risks. To help defray those risks: (a) advise participants how to recognize dangerous procedures; and (b) find out where they go for skin-piercing procedures (clinics, hospitals, cosmetic service providers, etc) and then visit those facilities to assess their efforts to prevent HIV transmission through skin-piercing procedures and, if deficient, advise them what to do better.

Warn participants about sex risks. To help defray sex risks: (a) trace and test sex partners, and if any are found HIV-positive, arrange couple counseling to warn participants at risk; and (b) distribute self-testing kits.

Ask participants to return to the study clinic  every three months for HIV tests and questions about risks. If a participant is found with a new infection despite all the advance advice and attention to possible risks, prevention didn’t work. Researchers, in other words, failed to protect them.

To find out what went wrong – to determine the source of the infection – ask about the participant’s possible sex and blood exposures in recent months. Then (re)trace and (re)test sex partners, and (re)visit facilities that provided skin-piercing procedures. If no sex risk is identified, test others attending suspected skin-piercing facilities to see if any facility infected others and thereby to zero in on the source.

After 6-9 months or so, once research staff have determined what failed to allow any new infections and have adjusted advice to participants and to health care and cosmetic service providers, the rate of new HIV infections should fall to zero. If not, researcher should be able to put their fingers on what went wrong. What was it? Do participants overlook risks? Do health care and cosmetic service providers continue unsafe procedures?

Decades of prevention research missed the point

Over more than 30 years, foreign-funded medical researchers in Africa recruited hundreds of thousands of men and women into trials to test various ways to protect them from getting HIV. Most such research repeated simple errors.

Not asking to investigate unexplained infections

Trials saw and reported HIV-positive men and women who denied sexual risk. None of the researchers involved publicly  recommended investigations to find how such participants got HIV. Here’s one of many examples:

  • A trial in Mpumalanga, South Africa saw 82 unexplained infections in young women. Among more than 2,000 women aged 13-20 enrolled in 2011-12, 38 who reported never having vaginal or anal sex were HIV-positive.[1] While following and retesting women through 2017, the study saw another 44 new infections in self-reported virgins. The study team considered unexplained infections as evidence of “misreporting on sexual behaviors.”[2,3]

By seeing unexplained infections but not recommending investigations, researchers failed to protect trial participants and other patients. They thereby violated ethical obligations laid out in the World Medical Association’s (WMA) Declaration of Lisbon: “Quality assurance should always be a part of health care. Physicians, in particular, should accept responsibility for being guardians of the quality of medical services.”[4]

Not protecting participants from sexual risks

No HIV prevention trial traced and tested sexual partners of trial participants at the beginning of the trial in order to warn participants if partners were infected. For example:

  • A 2016-19 trial enrolled and followed more than 3,000 women age 18-35 years at 15 sites across South Africa. Although 89% of the women reported a main sex partner at baseline, the study did not trace and test those partners to see if they were infected and thereby a risk for participants, During follow-up the study saw 239 new infections; women got HIV at the rate of 4.3%/year.[5]

A small minority of trials included spouses and other long-term partners and so tested them as well (without having to trace them), but even then, many such studies did not warn participants their spouses were infected. For example:

  • A 1989-97 study in Uganda (part of which was a trial) watched 12 husbands and 22 wives with infected partners get HIV. The study tested and followed adults without telling them their HIV status. An estimated 10% of all adults in the study nevertheless learned their HIV status from a local testing service. Tellingly, researchers reported (page 1088 in reference [6]: “we do not know whether individuals… share their test result with their spouse…  none of the HIV-negative adults in discordant marriages reported using a condom.”

Following participants without first testing partners and warning participants if partners were infected did not protect participants according to best practice. In the Uganda study noted in the above bullet, women with HIV-positive partners got HIV at 70 times the rate for women who had HIV-negative partners (10.5%/year vs 0.15%/year). Not protecting participants violates ethical principles in the World Medical Association’s Declaration of Helsinki noted above.[7]

Why were spouses left at risk? The HIV Prevention Trials Network coordinates a lot  of research in Africa. The Network’s guidelines advise caution not to protect participants too much: “…a very robust prevention package could potentially compromise the ability of a study to detect effects of the experimental modality, which undermines the scientific validity and social value of the research.”[8] 

Not warning partners, not identifying a sexual source

As far as I can see, no HIV prevention trial traced and tested sexual partners of participants who turned up with new HIV infections during the trial. By failing to do so, researchers did not establish a sexual source for new infections. For most trials, testing sex partners is not a big challenge; only small minorities of men and women in Africa report more than one sex partner in the past year (with some variation by country).

Moreover, when a participant shows up with a new HIV infection, not testing partners likely left many at risk. If a partner was HIV-negative (so the participant’s infection came from bloodborne transmission or another partner), the partner should be warned about his or her HIV risk. WHO endorsed this best practice as a “strong recommendation” in 2016 (page xvii in reference [9]): “Voluntary assisted partner notification services should be offered as part of a comprehensive package of testing and care offered to people with HIV.”

References

1. Pettifor A, MacPhail C, Selin A, et al. HPTN 068: a randomized control trial of a conditional cash transfer to reduce HIV infection in young women in South Africa – study design and baseline results. AIDS Behav 2016; 9: 1863-1882. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990514/ (accessed 18 December 2018).

2. Stoner MCD, Nguyen N, Kilburn K, et al. Age-disparate partnerships and incident HIV infection in adolescent girls and young women in rural South Africa: an HPTN 068 analysis. AIDS 2019; 33: 83-91. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/30289813 (accessed 10 May 2019)

3. Gisselquist, David and Collery, Simon, Indulging Sexual Fantasies Instead of Protecting Public Health: Not Acting on Evidence Young Women in South Africa Got HIV from Non-Sexual Risks (June 15, 2019). Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3405457 (accessed 10 January 2023.

4. World Medical Association (WMA). Declaration of Lisbon on the Rights of the Patient, 5 December 2022. WMA [internet]. Available at: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ (accessed 10 January 2023).

5. Gray GE, Becker L-G, Laher F, et al.  Vaccine Efficacy of ALVAC-HIV and Bivalent Subtype C gp120–MF59 in Adults. N Eng J Med 2021; 384: 1089-1100. https://www.nejm.org/doi/pdf/10.1056/NEJMoa2031499?articleTools=true. Supplementary information: https://www.nejm.org/doi/suppl/10.1056/NEJMoa2031499/suppl_file/nejmoa2031499_appendix.pdf   

6. Carpenter LM, Kamali A, Ruberantwari A, et al. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999; 13: 1083-1089.

7. WMA. Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 22 September 2022. WMA [internet]. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ (accessed 10 January 2023).

8. Brown B, Sugarman J. HPTN ethics guideline for research, revised February 2020. HIV Prevention Trials Network [internet]. Available at: https://www.hptn.org/sites/default/files/inline-files/HPTNEthicsGuidanceDocument_2.26.20.pdf (accessed 10 January 2023).

9. WHO. HIV self-testing and partner notification services: supplement to consolidated guidelines and HIV testing services. Geneva: WHO, 2016. Available at: https://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf (accessed 10 January 2023).

eSwatini: recent survey shows how to stop the country’s HIV epidemic


In December 2022, eSwatini’s Ministry of Health published results from a 2021 HIV survey.[1] Although the report does not say so, it shows how to stop the country’s HIV epidemic.

Most women’s infections not from sex

In 2021, women aged 15-49 years were getting HIV at the rate of 1.45% per year. Considering how many men were infected (18.7%) and how many had suppressed viral loads (86.1%), sex explains less than 0.3% of women getting HIV in a year. Hence, most women’s infections — >1.15% out of 1.45% — likely came from blood exposures during health care or cosmetic services, not sex.

Here’s how 2021 survey data show eSwatini women get HIV from sex at <0.3%/year:

  • From the survey 18.7% of men aged 15 and older were HIV-positive of which 86.1% had suppressed viral loads and were no threat to infect anyone through sex. [1]
  • Hence, only 2.6% (= 13.9% x 18.7%) of men were threats to infect their sex partners (18.7% were HIV-positive, but only 13.9% (= 1-86.1%)  of them had unsuppressed viral loads).
  • HIV-positive men with unsuppressed viral loads could be expected to infect 11% of steady sex partners in a year (this 11%/year rate comes from 5 studies that followed men and women in Africa who did not know they were infected; reference[2] summarizes evidence from 5 studies[3-7]).
  • Hence, if 2.6% of HIV-positive men with unsuppressed HIV had regular sex with HIV-negative women, men could be expected to infect 0.29% of women in a year (= 2.6% x 11%/year).
  • BUT 0.29%/year getting HIV from sex is an overestimate, since many HIV-positive men are celibate during any given year (>10% in a recent survey[8], or have partners who are already HIV-positive[9]; and/or use condoms when they don’t know the HIV status of partners.[8]

Finding and stopping bloodborne transmission

The beginning of the end of eSwatini’s HIV nightmare arrives as soon as people – workers, teachers, farmers, clergy, etc – recognize one or more unexplained HIV infections in their community, and for their own protection demand that government investigates. Investigations test others attending suspected source facilities, find more infected, and find specific facilities and procedures that transmitted HIV. Around the world, such investigations have uncovered local outbreaks with 100s to 1,000s of infections from medical procedures. The biggest was in China during 1990-95, with an estimated 100,000 infected when they sold blood and plasma.[2]

References

1. Ministry of Health, eSwatini. Population-based HIV impact assessment: summary sheet. New York: Columbia University, 2022. Available at: https://phia.icap.columbia.edu/wp-content/uploads/2022/12/53059_14_SHIMS3_Summary-sheet-Web.pdf (accessed 29 December 2022).

2. Gisselquist D. Stopping Bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available at: https://sites.google.com/site/davidgisselquist/stoppingbloodbornehiv (accessed 29 December 2022).

3. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342: 921-929. Available at: https://pubmed.ncbi.nlm.nih.gov/10738050/ (accessed 30 December 2022).

4. Carpenter LM, Kamali A, Ruberantwari A, et al. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999; 13: 1083-1089. Abstract only available at: https://pubmed.ncbi.nlm.nih.gov/10397539/ (accessed 30 December 2022).

5. Senkoro KP, Boerma JT, Klokke AH, et al. HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991 through 1996. J Acquir Immune Defic Syndr 2000; 23: 194-202. Abstract only available at: https://pubmed.ncbi.nlm.nih.gov/10737435/ (accessed 30 December 2022).

6. Hugonnet S, Mosha F, Todd J, et al. Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr 2002; 30: 73- 80. Abstract only available at:  https://pubmed.ncbi.nlm.nih.gov/12048366/ (accessed 30 December 2022).

7. Serwadda D, Gray RH, Wawer MJ, et al. The social dynamics of HIV transmission as reflected through discordant couples in rural Uganda. AIDS 1995; 9: 745-750. Abstract only available at: https://pubmed.ncbi.nlm.nih.gov/7546420/ (accessed 30 December 2022).

8. Ministry of Health, Swaziland. Swaziland HIV incidence measurement survey 2 (SHIMS 2) 2016-17. New York: Columbia, 2019. Available at: https://phia.icap.columbia.edu/wp-content/uploads/2020/02/SHIMS2_Final-Report_05.03.2019_forWEB.pdf (accessed 29 December 2022).

9. Central Statistical Office, Swaziland. Swaziland Demographic and Health Survey 2006-07. Calverton (MD): Macro International; 2008. Available at:  https://dhsprogram.com/publications/publication-fr202-dhs-final-reports.cfm (accessed 29 December 2022).

Protect women? Investigate unexplained HIV infections, and shun dangerous interventions


[Note: This blog responds to news that Wits University, South Africa, plans to promote HIV pre-exposure prophylaxis (PrEP) to women through pills, injections and vaginal rings.][1,2]

To protect African women from HIV – to protect yourself, too – pay attention to HIV in women with no sex risks. Women go for a lot of sex-related health care: pregnancy care, child delivery, birth control injections, etc. When skin-piercing procedures in health care and cosmetic services transmit HIV, women are on the front lines.

Ignoring unexplained infections, Africa’s government health agencies operate with the fiction that almost all HIV-positive adults got it from sex. That fiction denies evidence, which says bloodborne transmission is more common than sexual transmission.[3] Many HIV/AIDS experts in and outside Africa who promote the sex-does-it-all fiction know it’s wrong (but lie). Many health staff – along with much of the general public – are not aware it’s fiction. 

Most women avoid sexual exposure to HIV with condoms and tested partners. But if they believe the sex-does- it-all lie, they aren’t alert to avoid unsterilized skin-piercing instruments in health care and cosmetic services. So they get HIV from blood, not sex.

Building on the fiction that sex accounts for most infections, health experts and agencies (WHO, UNAIDS, others) push new medical interventions for women in Africa to use to protect themselves from HIV via sex. Three such interventions deliver antiretroviral medicine for pre-exposure prophylaxis (PrEP) in: daily pills, injections, and vaginal rings.

PrEP pills

In 2015, WHO recommended young HIV-negative African women at high risk for HIV (in communities where ~3% or more get HIV every year) to take PrEP pills daily to prevent HIV infection after exposure.[4] Currently, most PrEP pills deliver two antiretroviral medicines, tenofovir and emtricitabine, or TDF-FTC.

PrEP pills work. If taken daily, they will almost always stop HIV: In a trial among men-who-have-sex-with-men (MSM) reported in 2014, “No infections occurred during periods when drug concentrations were commensurate with use of 4 or more tablets per week.”[5] PrEP stops bloodborne transmission as well: In a trial reported in 2013, PrEP pills reduced new infections among injection drug users in Thailand by almost half.[6]

Table: Selected complaints from women taking PrEP pills in a 2017-20 trial in Africa[7]

Adverse event% of women complaining
Gastrointestinal disorders23%
Abnormal uterine bleeding19%
Headache17%
Upper respiratory tract infection19%
Back pain7%

Nevertheless, in multiple trials in Africa, women taking PrEP pills got HIV as fast as women taking placebo pills (with no medicine).[8] The problem seems to have been that many women believed the lie that almost all HIV comes from risk. Because PrEP gives women diarrhea, headaches, body aches, etc (see Table), many women skipped pills when they had no sex risks. Then they got HIV from unsuspected bloodborne risks.

Cabotegravir injections

To overcome the problem of women not taking PrEP pills, prominent foreign agencies including WHO,[9] USAID,[10] and others urge African governments to offer cabotegravir PrEP injections every eight weeks. Zimbabwe approved cabotegravir PrEP in 2022, and South Africa is expected to do so in early 2023.[1] 

Unlike TDF-FTC from pills, which stays in bodies for days only, the injected cabotegravir stays in blood for months, escaping slowly over time. An injection every eight weeks keeps blood levels high enough to stop most (not all!) new HIV infections. Two recent trials comparing cabotegravir vs. pills found that both stopped HIV, except that pills didn’t work when people didn’t take them:

  • A 2017-20 trial in Africa divided women into two “arms.” Women in one arm got cabotegravir injections every 8 weeks; women in the other got TDF-FTC pills.[7] The study reported 4 new HIV infections with cabotegravir vs. 36 with TDF-FTC. However, (quote from page 1784): “Poor or non-adherence (<2 doses per week) was observed in most TDF-FTC incident [new] infections (35 [98%] of 36).”
  • A similar trial followed MSM in the US and six other countries during 2016-20.[11,12] In this study as well (quote from page 607 in[11]), “…inadequate TDF–FTC adherence among some participants appeared to drive the overall finding of [lower] HIV incidence… in the cabotegravir group…”

The two trials mentioned above reported unpleasant side effects along with serious health threats. In the African trial, women’s complaints with cabotegravir were similar to those with PrEP pills (Table above). In additional, trials reported:

  • Liver damage: In the trial among MSM, more than 2% quit the trial because of “liver-related adverse events.”
  • HIV resistance: Because medicine from injections stays in the blood for a long time, it can mask new infections, allowing HIV to multiply and accumulate resistance mutations. The trial among women in Africa saw 5 cases of resistance; the trial among MSM reported resistance and delays in seeing new infections.

The “sales pitch” for cabotegravir for African women is injections every two weeks take away women’s day-by-day control over PrEP drugs in their blood. With cabotegravir they can’t stop PrEP on days they don’t have sex risks. Will women accept cabotegravir? Women who are persuaded – somehow – to take it will suffer unpleasant and health-threatening side effects but will be protected from bloodborne as well as sexual transmission. However, any such benefits to some women leave others – men, women, children – exposed to continuing bloodborne transmission in health care and cosmetic services.

Vaginal rings with dapivirine

The European Medicines Agency in 2020 approved dapivirine vaginal rings for women outside the EU.[13] In 2021, WHO recommended rings for women at high risk.[14] Through end-2022, governments of Zimbabwe, South Africa, and several other countries approved the rings.[15]

Current enthusiasm for vaginal rings with dapivirine (an antiretroviral) conflicts with less-than-impressive results from two 2012-15 trials.

  • Ring trial: Women aged 18-45 in South Africa and Uganda got HIV at the rate of 4.1%/year with dapirivine rings and 6.1%/year with placebo rings (without medicine).[16]
  • Aspire trial: Women aged 18-45 years in South Africa, Malawi, Uganda, and Zimbabwe got HIV at the rate of 3.3%/year with dapivirine rings, and 4.5%/year with placebo rings.[17]

Sex risks? In the Ring trial, 98% reported a main sex partner. In the Aspire trial 57% reported using a condom at their last sex act, 41% were married, and 97% reported having the same primary partner for the past 3 months. In both trials, women reported an average of 2 vaginal sex acts per week. With such behavior, half to two-thirds or more of their primary partners would have to be HIV-positive for sex to account for observed new infections, which is absurd (in the Aspire trial, 1% of women knew their primary partner was HIV-positive, 55% knew he was HIV-negative, and 43% did not know[18]). Considering women’s limited sex risks, bloodborne transmission likely accounted for most new infections in both trials.

Did the rings work at all? Comparing dapivirine rings to placebo rings is misleading. Both rings disturb the vagina (inflammation, different microbes), favoring sexual transmission. That seems to have happened in a previous study comparing antiretroviral vaginal gel to a placebo gel – and to placebo daily pills. Women with either gel got HIV faster than women with placebo pills (6.0% with antiretroviral gel, 6.8% with placebo gel, but only 4.6% with placebo pills).[19] Furthermore, the modestly lower rate of new infections in women using dapivirine vs. placebo rings might have had nothing to do with sexual transmission, but might have been due to trace amounts of dapivirine in blood blocking bloodborne transmission.

As demonstrated in the trials, dapivirine rings are disasterouse failures. The trials saw women using them get HIV at 3.3%-4.1%/year. At those rates, 33%-44% of women would be HIV-positive in 10 years. Women who want to avoid HIV should rely on something else.

Conclusion: Protecting women takes a back seat to professional self-interest

Knowing how women get HIV could guide programs to reduce their risks. Trials among women in Africa discussed above (one for cabotegravir, two for vaginal rings) could have looked for risks that infected women. They didn’t. None tested partners after women got HIV. Without testing trials cannot confirm sexual transmission. As for bloodborne risks, none of the trials asked about and reported skin-piercing events in health care and cosmetic services.

Experts directing many other studies among women in Africa display similar lack of curiosity about how women got HIV at high rates. For example:

  • A 2016-19 trial of a candidate HIV vaccine in 15 sites across South Africa reported women aged 18-25 years got HIV at the rate of 4.7%-4.4%/year (the higher rate was in women taking the candidate vaccine).[20]
  • A 2015-18 trial to see the impact of various birth control technologies on women’s HIV risk enrolled women aged 16-35 years in nine sites across South Africa. The overall rate at which women got HIV was 4.5%/year, going as high as 6.8%/year at a site in KwaZulu-Natal.[21]

Neither of these trials – high profile, with lots of resources to ask about anything – tested partners, and neither asked about and reported bloodborne risks. Without evidence, trial reports simply assumed sexual transmission, even though the rates at which women got HIV were too high to be explained by sex.

If protecting women is the goal: (a) governments should investigate unexplained infections to find and stop bloodborne transmission; (b) trials (such as cited here) should look for women’s sex and bloodborne risks; (c) based on what experts learn from (a) and (b), public health programs should warn women about bloodborne risks; and (d) public health programs should stop abusing HIV-positive women by saying almost all HIV comes from sex.

In promoting PrEP pills, injections, and rings for women in Africa, health staff at WHO, European Medicines Agency, USAID, Wits, and other organizations have chosen the self-serving option – protecting their reputations by ignoring unexplained infections that likely came from unsafe health care, and promoting new medical interventions which expand health agencies and incomes even though proposed impacts on HIV sexual transmission are suspect and come with health threats. For sure, special circumstances might warrant these technologies for some people, such as MSM, some prostitutes, and women who want to get pregnant by HIV-positive men with uncontrolled viral loads. But most women in Africa, if warned of all sex and bloodborne risks, can protect themselves without PrEP in any form.

References

1. Gonzalez LL. South Africa to begin piloting injectable PrEP in early 2023. NAM [internet] 7 November 2022. https://www.aidsmap.com/news/nov-2022/south-africa-begin-piloting-injectable-prep-early-2023.

2. Gonzalez LL. South Africa: Pilot projects set to inform rollout of HIV prevention shot. allAfrica [internet] 2022. https://allafrica.com/stories/202211220372.html.

3 Gisselquist D. Recognizing and stopping blood-borne HIV transmission. SSRN [internet] 2 August 2022. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4174723.

4. WHO expands recommendation on oral pre-exposure prophylaxis of HIV infection (PrEP). Geneva: WHO; 2015. https://www.paho.org/sites/default/files/2020-03/cover-eng_46.jpg.

5. Grant RM, et al. An observational study of preexposure prophylaxis uptake, sexual practices, and HIV incidence among men and transgender women who have sex with men. Lancet Infect Dis 2014; 14: 820-829. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107918/pdf/nihms624706.pdf.

6. Choopanya K, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomized, double-blind, placebo controlled phase 3 trial. Lancet 2013, 381: 2083-2090.

7. Delany-Moretlwe S, et al. Cabotegravir for the prevention of HIV-1 in women: results from HPTN 084, a phase 3, randomised clinical trial. Lancet 2022; 399: 1779-89. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9077443/pdf/main.pdf.

8. Gisselquist D. Women’s estimated HIV infections from sex in trials of pre-exposure prophylaxis in Africa: Implications for HIV prevention strategies. bioRxiv [internet] 8 June 2017. https://www.biorxiv.org/content/10.1101/146530v1.full.pdf.

9. Guidelines on long-acting injectable cabotegravir for HIV prevention. Geneva: WHO, 28 July 2022. https://www.who.int/publications/i/item/9789240054097.

10. USAID’s Approach to HIV and Optimized Programming. Washington, DC: USAID, 2022. https://www.usaid.gov/sites/default/files/2022-12/HIV_Report_F_single_508.pdf.

11. Landovitz RJ, et al.,Cabotegravir for HIV Prevention in Cisgender Men and Transgender Women. N Eng J Med 2021; 385: 597-608. https://www.hptn.org/sites/default/files/inline-files/nejmoa2101016.pdf.

12. Marzinke MA, et al. Characterization of HIV infection in cisgender men and transgender women who have sex with men receiving injectable cabotegravir for HIV prevention: HPTN 083. J Infect Dis 2021; 224: 1581-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8599849/.

13. EMA. Dapivirine Vaginal Ring 25 mg: opinion on medicine for use outside EU (dapivirine). EMA [internet] 24 July 2020. Available at: https://www.ema.europa.eu/en/opinion-medicine-use-outside-EU/human/dapivirine-vaginal-ring-25-mg  (accessed 16 December 2022).

14. WHO recommends the dapivirine vaginal ring as a new choice for HIV prevention for women at substantial risk of HIV infection. Geneva: WHO, 2021. https://www.who.int/news/item/26-01-2021-who-recommends-the-dapivirine-vaginal-ring-as-a-new-choice-for-hiv-prevention-for-women-at-substantial-risk-of-hiv-infection.

15. International Partnership for Microbicides (IPM). Dapivirine ring. IPM [internet]. https://www.ipmglobal.org/our-work/our-products/dapivirine-ring.

16. Nel A, et al. Safety and efficacy of a Dapivirine vaginal ring for HIV prevention in women. NEJM 2016; 375: 2133-43. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1602046.

17. Baeten JM, et al. Use of a vaginal ring containing dapivirine for HIV prevention in women. N Eng J Med 2016; 375: 2121-32. https://www.nejm.org/doi/full/10.1056/nejmoa1506110.

18. Palanee-Phillips T, et al. Characteristics of women enrolled into a randomized clinical trial of dapivirine vaginal ring for HIV-1 prevention. PLOS ONE 2015; 10: e0128857. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4489588/.

19. Marrazzo JM, et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. N Eng J Med 2015; 372: 509- 518, with supplementary materials. https://www.nejm.org/doi/full/10.1056/nejmoa1402269.

20. Gray GE, et al.  Vaccine Efficacy of ALVAC-HIV and Bivalent Subtype C gp120–MF59 in Adults. N Eng J Med 2021; 384: 1089-1100. https://www.nejm.org/doi/pdf/10.1056/NEJMoa2031499?articleTools=true.

21. Palanee-Phillips T, et al. High HIV incidence among young women in South Africa: Data from a large prospective study.  PLoS One 2022; 17: e0269317. https://pubmed.ncbi.nlm.nih.gov/35657948.

Ebola, Uganda and the Shadow of the Media


If there was an outbreak of a potentially deadly virus, one that has been a headline ‘pandemic’ in the past, you’d expect to see it emblazoned across the mainstream media. Their health correspondents would be drooling over exotic offerings from the usual experts, Drs Piot, Ferguson, Fauci, people from WHO, CDC, SAGE and others.

There would be dire predictions based on complex (but highly mysterious) ‘models’, all ‘international’ coverage would be echoed around the ‘social’ media sector of the mainstream media. There would be titillating stories about lurid practices alleged to give rise to this virus, which must have come from ‘somewhere else’.

If the case fatality rate was higher than 40%, compared to the 0.04% death rate recently estimated from monkeypox virus, and the virus in question this time was Ebola, you’d expect to hear more about it than we have heard about monkeypox virus, right?

But not when it occurs in Uganda, it would seem. Whether you read the fairly cautious Infectious Diseases Society of America’s report, or the Wikipedia coverage (now that they and their peers have fallen in with the mainstream when it comes to well branded epidemics and pandemics), the current outbreak in Uganda is extremely serious.

There are a few other media stories, but this has not been deemed worthy of front page coverage or breathless interviews with people in spacesuits ‘on the frontline’. Weren’t we promised vaccines during the ebola epidemics in several West African countries a few years ago?

Media coverage of disease outbreaks and other disasters has no correlation with the severity or extent of the occurrence. What determines worthiness to be graced with genuine concern and attention?

Living forward – understanding and stopping Africa’s HIV disasters


“And now these three remain: faith, hope and love. But the greatest of these is love.”

Bible, New International Version, 1 Corinthians 13: 13

Introduction: understanding more important than justice

In this blog, I apply 1 Corinthians 13: 13 to Africa’s unnecessary HIV disasters – unnecessary because they have been driven for decades by easily avoidable blood exposures during health care, not by sex (a minor contributor).

Note the verse says nothing about justice. In the case of Africa’s HIV epidemics, going for justice can be an obstacle to seeing and fixing what went wrong. Going for justice motivates people to hide mistakes, not only from others but also from themselves – not recognizing what they have done and/or inventing excuses to avoid self-judgment. (Personal note: Considering what I’ve done over 75 years, I’d rather have mercy than justice anytime.)

Instead of going for justice, let’s have hope and faith that people will see and fix errors. Love looks forward – wanting people to be healthy in body and spirit. Justice looks backward.

I say this to introduce a fairly simple issue: Explaining what went wrong to cause Africa’s HIV epidemics. It’s not possible to explain what went wrong without saying people made mistakes – in effect, blaming them for causing Africa’s disasters. But my blaming here is intended simply to explain what happened, and does not ask for justice.

Thumbnail sketch of errors that cause Africa’s HIV epidemics

The crucial error that allowed Africa’s HIV disasters was not warning people about HIV from bloodborne risks. For the sake of understanding how that error led to Africa’s HIV epidemics, it’s useful to consider several groups:

  • The source of misinformation: Beginning in the mid-1980s experts in WHO and in African and foreign governments and universities who were trained to understand disease transmission and charged to explain Africa’s HIV epidemics betrayed their training and ethical responsibility. Instead of explaining Africa’s epidemics, they promoted a specific and deadly double standard: Assuring Africans their health care was safe enough for them, but warning foreigners to avoid skin-piercing procedures in Africa. Continuing this double standard for more than 35 years, public health experts leading the international response to Africa’s HIV epidemics have neither warned Africans about risks to get HIV from medical procedures, nor done what is necessary to find and stop bloodborne transmission.
  • Infecting patients: Following bad expert advice, thousands of front-line health staff in Africa unknowingly infected patients through procedures they thought were safe, but were not. Some surely recognized infections best explained by unsafe health care, but did not push for investigations to find their source, accepting experts’ assurances that such infections were rare.
  • Spreading misinformation and stigma: Following and believing bad expert advice, millions of teachers, reporters, NGO staff  and others disseminated misinformation – encouraging people to trust unsafe heath care and stigmatizing HIV-positive youth and adults for imagined sexual misbehavior.
  • Parallel human rights failure: Beginning in the 1980s, human rights experts and organizations accepted the above double standard (health care safe enough for Africans, but not foreigners) as well as HIV-related research that violated established ethical guidelines. Human rights experts should have called out bad advice that killed Africans, but they didn’t.

How understanding what happened can help stop Africa’s HIV epidemics

The way to stop bloodborne HIV transmission is simple and proven: Investigate unexplained infections. As has happened elsewhere, investigations that uncover outbreaks with hundreds to thousands of people with HIV from medical procedures will motivate everyone – including the general public – to do whatever is required to stop bloodborne transmission. That stops Africa’s HIV disasters.

Across sub-Saharan Africa, HIV testing year-by-year exposes unexplained infections in people with no sexual or mother-to-child risks. No doubt  many people who have or know of such infections have talked with friends and neighbors, getting information about other local unexplained infections and considering which clinics or other facilities might have infected them through skin-piercing procedures.

In communities outside sub-Saharan Africa – in Libya, Cambodia, Pakistan, and elsewhere – such informal investigations have gotten into the press and pushed  governments to help with expanded investigations. Building on local informal investigations, governments organized widespread testing, finding more victims and thereby tracing HIV transmission to specific medical facilities and procedures. So far that has not happened in sub-Sahara Africa.

Understanding is important from the bottom up: The more people in the general public are aware of the lies they have been fed – that bloodborne risks infect few Africans – the more likely it will be that they will press reluctant governments to investigate. As people in one community after another ask African governments to help with expanded investigations, and as governments investigate, the truth will overcome experts’ decades of misinformation.

What to do about those who made errors?

Errors caused deaths and sorrows. As of 2022, Africa’s HIV epidemics killed more than 20 million from the time HIV was recognize in the 1980s (see UNAIDS estimates for 1990-2021; warning Africans about bloodborne risks from the mid-1980s could have prevented most of these deaths from bloodborne as well as follow-on sexual and mother-to-child transmission). Tens of millions more are living with infections. Numbers compare with some of the worst wars in history. The human experiences are hard to imagine even person-by-person, much less the scope of the disaster.

Even so: I don’t advocate justice. It wouldn’t bring victims back to life or restore them to health. Most importantly: Going for justice obstructs understanding what went wrong, and thereby blocks finding and fixing errors at all levels – by health bureaucrats, scientists, front-line health staff, and others.

The “ring-leaders” of the misinformation that caused Africa’s HIV epidemics are, as noted above, influential health experts in universities and government organizations. My blaming them for that is not intended to lead to justice. Not going to happen. But understanding who did what might reduce trust and respect for people who  should have known and done better. There are future health policy issues to consider – is it good for health in and out of Africa to trust such people to guide future policies?

With bad information from influential experts, many  people got caught up in the disaster. For example, many front line health staff unknowingly infected patients. It is not possible to find all who did so. Uncertainty is unavoidable. Nevertheless, health staff who understand what happened will be motivated to be more careful in the future, and will save lives with their skills. Self-forgiveness can help them recover and continue to deliver (safe) health care.

As for all others who spread misinformation – they have to learn new stories. It’s been too easy for too many people to fall into moralistic or racist explanations. Lots to do, lots to change.



New evidence bloodborne transmission explains most HIV infections in sub-Saharan Africa  


What new evidence?

            Studies that collect HIV from people in a community and then describe how each person’s HIV is organized (sequence their HIV) can find out how HIV has been spreading in the community. People with similar HIVs very likely have linked infections – one infected the other directly or indirectly (through one or more others). If sex is the most important risk, a lot of sex partners would have similar HIVs. If a lot of people with similar HIVs have no sexual connection, then blood-borne transmission must be infecting a lot of people.

            To see what such studies show about how HIV transmits in Africa, we looked at large studies that collected and sequenced from at least 100 adults in a community-based survey (we included studies that sequenced additional HIV collected during local health activities). Most evidence is recent: 9 of 13 studies meeting those criteria were published in 2017 or later.

New evidence: Not much sexual transmission within households!

            Five of 13 studies give good information about the percentages of HIV infections that may be coming from sex within households. These five studies collected HIV from all willing adults in sampled households and identified couples (spouses, steady partners, or men and women living together) with similar sequences.

            For example, a 2010-13 study in Mochudi town, Botswana, looked for similarities among 833 sequenced HIVs representing half of the HIV-positive adults (age 16-64 years) in the community.[1] The study found 322 sequences similar to one or more others, including 30 in 15 pairs from men and women living together. Assuming they were sex partners (the study does not say one way or the other), one partner likely infected the other, providing a sexual explanation for only 1.8% (=15/833) of Mochudi adults with sequenced HIV.

            The other four studies with information to estimate sexual transmission within households [2-5] identified couples with similar HIV sequences to explain from 0.3% of adults with sequenced HIV in a study area in South Africa up to 7.5% in a study area in Malawi (Figure 1). Some men and women who infected household sex partners may have been missed in these studies (not home, not wanting to give blood, divorced, or died), and studies may have mistakenly said some couples had dissimilar sequences. But even if household sexual transmission was 2-3 times greater than estimated from evidence (Figure 1), it would still account for small percentages of HIV infections in any of the studied communities.

New evidence: Bloodborne transmission dominates outside the home

            None of the articles that met our search criteria identified any short-term sexual partners. Hence, to see the frequency of sexual or blood-borne transmission outside the home we considered the sex of people linked in non-household pairs with similar HIVs. We found five studies that reported the sex of people paired together outside the home (see Table 1). Two of these five studies took HIV from only one adult in each sampled household (7,9), and three identified man-woman household pairs, which we exclude in Table 1.

            If sexual transmission accounts for most infections outside the home, one would expect to see mostly man-woman pairs. On the other hand, if people get HIV from contaminated instruments in health care or cosmetic services, then the previous HIV-positive patient or client whose HIV contaminated the transmitting instrument could be either a man or a women – and one could expect an equal percentage of same-sex vs. men-women pairs. (However, some settings with skin-piercing events might serve mostly one sex, such as antenatal clinics, which could cause some bias towards same-sex pairs outside the home.)

            What do the data show? In three of five studies, same sex pairs account for 59% or more of non-household pairs. Overall, combining data from the five studies, 45% of non-household pairs are same-sex. Near 50% frequency of same-sex non-household pairs suggests that most transmission events outside the home were influenced more by chance (e.g., the last previous patient at a hospital or dental clinic) than by sex.

country, yearsnumber of pairs% same-sex pairs% man-woman pairs
Kenya, 2003-5(6)786%14%
South Africa, 2014-15(7)16859%41%
Uganda, 2009-11(8)2259%41%
Uganda, 2011-1(5)36145%55%
Zambia, 2014-18(9)80442%58%

Similar HIVs in people living too far apart to be sexual partners

            Comparing the locations of two or more non-household adults with similar HIVs and reported or reasonable locations for non-household sex partners undermines the view most infections outside the home come from sexual transmission. Consider evidence from two studies:

  • From HIV collected in Rakai District, 2008-9, similar sequences were more likely to link people from different communities compared to reported non-household sex partnerships. Among clusters (two or more similar HIVs) that linked people outside the home, 72% (=38/53) linked people from two or more Rakai communities, whereas only 28% (=929/3,271) of reported non-household sex partners in the previous year lived in other communities in Rakai District.[4]
  • A study in Botswana in 2013-18 identified 25 (page 20 in[10]) “highly supported probable source-recipient [man-woman] pairs,” which linked men and women living a median of 161 kilometers apart; 1/4th lived at least 420 kilometers apart. Similar sequences in people living so far apart may be better explained by unsafe practices at a hospital or other skin-piercing facility serving a large area than by sexual liaisons.

Large groups of people with similar HIVs from new infections

            Two studies report 63 and 10 people with similar HIVs from new infections. Both studies collected blood from a minority of adults in the study area, so the total number with new and linked infections was likely much larger. But even 63 and 10 new infections are hard to explain by heterosexual transmission (which takes on average years, even between married people unaware one is infected, and with regular unprotected sex). On the other hand, such rapid transmission has been documented in HIV outbreaks from health care in other countries (e.g., Russia[11] and Cambodia[12]).

            Here are some details about these African clusters:

  • A study in KwaZulu-Natal, South Africa, found a cluster of 63 similar HIVs from recent infections. From similarities among sequences, researchers estimated HIV from one person in mid-2013 reached and infected, directly and through others, 63 people over 18 months.[13] This was likely part of a much larger cluster: it was found in HIV representing circa 15% of infected adults in the study area.
  • A study of HIV sequences from villages in southern Cameroon, 2011-13, identified a (page 10 in[14]) “recent transmission” linking 10 women in five villages along a road.

Conclusion: Stopping Africa’s blood-borne HIV transmission

            From this evidence, blood-borne transmission almost certainly accounts for a large proportion, and likely a large majority, of HIV infections in Africa. Stopping bloodborne transmission is the key to stopping Africa’s HIV epidemics.

            Whatever the scale of blood-borne transmission, the best way to stop it is to investigate unexplained infections (e.g., in adults with no sexual risks; in children with HIV-negative mothers), testing widely to find other victims, and thereby trace unsafe procedures. Throughout Africa HIV testing year-by-year exposes thousands of unexplained infections. When people talk within their communities about such infections, that is already an informal investigation. When and if such sharing finds more unexplained infections and focuses suspicions on specific facilities, sooner or later reports reach local media and government officials..

           Will new evidence change anything? If and when African communities start informal investigations into unexplained infections, will new evidence from sequencing encourage government leaders to respond favorably when communities ask for help to find more people infected from the same sources and to trace and stop dangerous procedures?

[Note: this post by Gisselquist and Collery is a short version of their article, which is available for free download on SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4174723.[17] The full article describes the literature search and more details about the new evidence.]

References

1. Novitsky V, Bussmann H, Okui L, et al. Estimated age and gender profile of individuals missed by a home-based HIV testing and counselling campaign in a Botswana community. J Int AIDS Soc 2015; 18: 19918. Available at: https://dash.harvard.edu/bitstream/handle/1/17295521/4450241.pdf?sequence=1&isAllowed=y (accessed 30 May 2022).

2. McCormack GP, Glynn JR, Crampin AC, et al. Early evolution of the human immunodeficiency virus type 1 subtype C epidemic in rural Malawi. J Virol 2002; 76: 12890-12899. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC136717/pdf/1239.pdf (accessed 10 June 2022).

3. Cuadros DF, de Oliveira T, Graf T, et al. The role of high-risk geographies in the perpetuation of the HIV epidemic in rural South Africa: A spatial molecular epidemiology study. PLOS Glob Pub Health 2022; 2: e0000105. Available at: https://journals.plos.org/globalpublichealth/article/comments?id=10.1371/journal.pgph.0000105 (accessed 25 June 2022). Supplementary information available at: https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000105#sec017 (accessed 25 June 2022).

4. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS Med 2014; 11: e1001610. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942316/ (accessed 17 June 2022).

5. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4 (accessed 17 June 2022).

6. Zeh C, Inzaule SC, Ondoa P, et al. Molecular epidemiology and transmission dynamics of recent and long-term HIV-1 infections in rural Western Kenya. PLoS ONE 2016; 11: e0147436. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752262/pdf/pone.0147436.pdf (accessed 25 June 2022).

7. de Oliveira T, Kharsany ABM, Gräf T, et al. Transmission networks and risk of HIV infection in KwaZulu-Natal, South Africa: a community-wide phylogenetic study. Lancet HIV 2017; 4: e41–e50. Available at: https://pubmed.ncbi.nlm.nih.gov/27914874/ (accessed 27 April 2022).

8. Kiwuwa-Muyingo S, Nazziwa J, Ssemwanga D, et al. HIV-1 transmission networks in high risk fishing communities on the shores of Lake Victoria in Uganda: a phylogenetic and epidemiologic approach. PLoS One 2017; 12: e0185818. Available at:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638258/ (accessed 6 June 2022).

9. Hall M, Golubchik T, Bonsall D, et al. Demographic characteristics of sources of HIV-1 transmission in Zambia. medRxiv [internet] 9 Oct 2021. Available at: https://www.medrxiv.org/content/medrxiv/early/2021/10/07/2021.10.04.21263560.full.pdf (accessed 15 May 2022).

10. Magosi LE, Zhang Y, Golubchik T, et al. Deep-sequence phylogenetics to quantify patterns of HIV transmission in the context of a universal testing and treatment trial – BCPP/Ya Tsie trial. eLife 2022; 11: e72657. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8912920/pdf/elife-72657.pdf (accessed 27 April 2022).

11. Pokrovsky VV. Localization of nosocomial outbreak of HIV-infection in southern Russia in 1988-1989. 8th Int Conf AIDS. 19-24 July 1992; abstract no. PoC 4138. Available at: https://quod.lib.umich.edu/c/cohenaids/5571095.0050.029?rgn=main;view=fulltext  (accessed 28 June 2022).

12. Vun MC, Galang RR, Fujita M, et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. MMWR Morb Mortal Wkly Rep 2016; 65: 142-145. Available at:

13. Coltart CEM, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventionsConference on Retroviruses and Opportunistic Infections, Boston, 4-7 March 2018. Abstract 47LB and oral abstract. Available at: AHRI research at CROI 2018 – Africa Health Research Institute (accessed 1 June 2022).

14. Edoul G, Ghia JE, Vidal N. et al. High HIV burden and recent transmission chains in rural forest areas in southern Cameroon, where ancestors of HIV-1 have been identified in ape populations. Infect Genet Evol  2020; 84: 104358. Available at: https://europepmc.org/article/med/32439500 (accessed 25 June 2022).

Time to let go of sexual fantasies about Africa’s HIV epidemics


For decades, too many experts in health agencies and universities have said most HIV in Africa comes from sex. Some does, of course. But most does not. Blaming sex never fit facts – many, many HIV-positive Africans knew and said they did NOT have any sexual risk. Too many experts didn’t believe them.

Finally, we have new evidence to challenge experts’ sexual fantasies. This new evidence comes from looking at each person’s HIV. It does not[!] depend on what anyone says about their sexual behavior.

Sequencing to see who infected whom

Each HIV is made of small pieces (nucleotides) in a particular order, which is called its “sequence.” HIV sequences change bit-by-bit over time. Comparing HIV sequences from two or more people can show how closely their infections are related. If sequences are very similar, one person likely infected the other.

To see how HIV infections have been moving through a community, researchers can take HIV from lots of people in the community, sequence the HIV they collect, and then look to see who has similar sequences. Similar sequences may be in pairs or in larger groups (clusters) of three or more sequences.

Here’s where it gets interesting for Africa: When a study has sequenced a lot of HIV from a community, those sequences can show how many people got HIV from known sex partners, and how many got HIV from other unidentified risks (sex or blood).

What percentage of HIV infections in Africa come from known sex partners

From 2013-2022, five studies sequenced HIV from hundreds to thousands of people in communities in Africa and said how many pairs of similar sequences came from known sex partners. Across these five studies, the percentages of HIV infections explained by known sex partners ranged from 0.3% to 6.6% (see Figure 1, below). All known sex partners were spouses or steady partners (I include suspected partners living together in these percentages).

Studies no doubt missed some spouses who were not at home or did not want to give a blood sample. And studies did not have information on who was a short-term sex partner. But if sex was responsible for even 1/3rd of HIV infections in these communities, missing spouses and short-term partners would have to infect many times more people than identified steady partners.          

Here’s are some details about what these five studies report (Figure 1, and paragraphs following the figure).

Evidence from Mochudi, Botswana

During 2010-13, researchers collected HIV from more than 1,200 adults in Mochudi, a town north of Gaborone, the capital. They sequenced about 2/3rds of the HIV they collected. Two reports give similar but slightly different information about numbers of infections explained by sex:

  • (a) One study, using 785 sequences from Mochudi, found 191 sequences to be similar to one or more others, including 4 pairs from men and women living together.[1] The study does not say they were sex partners. But assuming they were, the study identified sexual links to explain 4 infections: In each pair, one person likely infected the other, but the study cannot say how the first person in each pair got HIV. Hence, the study identified a sexual source for 0.5% (=4/785) of HIV sampled and sequenced from Mochudi.
  • (b) A second study, using 833 sequences from Mochudi, found 322 to be similar to one or more others, including 15 pairs from men and women living together.[2] The study does not say if they were sex partners. Assuming they were, the study found a sexual source for 15 infections, or 1.8% (=15/833) of HIV sampled and sequenced.

Evidence from KwaZulu-Natal, South Africa

In 2011-14, a study collected HIV samples from more than 5,000 adults in a community in uMkhanyakude, KwaZulu-Natal, South Africa.[3] The study sequenced 1,222 HIV from people with known addresses. Among these 1,222 sequences, the study found 333 that were similar to one or more other sequences. Similar sequences included 4 pairs from men and women living together who were not more than five years apart in age. The study does not say if they were sex partners. Assuming they were, the 4 pairs provide a sexual explanation for 4 infections, or 0.3% (=4/1,222) of HIV sequenced and with information on residence.

Evidence from Rakai, Uganda

Two studies sequenced HIV collected in long-term study communities in Rakai District, Uganda. The two studies collected HIV in different years from some of the same but also some different communities. Here’s what they report about sequences and sex partners:

  • One study sequenced 1,099 HIV collected in 2008-9.[4] The study found 209 sequences to be similar to one or more others, including 51 pairs from known couples (married or stable partners). These 51 pairs provided a sexual explanation for 51 infections, or 4.6% (=51/1,099) of infections with sequenced HIV.
  • The second study sequenced 2,652 HIV collected in 2011-15. The study found 1,334 sequences in clusters (that is, similar to one or more others), including 176 pairs from couples.[5] This provides a sexual explanation for 176 infections, or 6.6% (=176/2,652) of HIV sequenced.

Let go of sexual fantasies! What next?

For years, experts denied evidence – saying HIV-positive African who said they were virgins or had one HIV-negative lifetime partner were lying about their sexual behavior . But as Figure 1 shows, only small minorities of HIV infections can traced to known sex partners with similar HIV sequences. This evidence cannot be rejected by saying people lied about their sexual behavior.

It’s time to let go of sexual fantasies. And It’s LONG past time to get serious about finding and stopping HIV transmission from careless and unsafe skin-piercing procedures in health care and cosmetic services. How? Investigate unexplained infections (see menu on the right).

References

1. Novitsky V, Bussmann H, Logan A, et al. Phylogenetic relatedness of circulating HIV-1C variants in Mochudi, Botswana. PLoS One. 2013; b: e8059, DOI:10.1371/journal.pone.0080589. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24349005 (accessed 24 July 2017).

2. Novitsky V, Bussmann H, Okui L, et al. Estimated age and gender profile of individuals missed by a home-based HIV testing and counseling campaign in a Botswana community. J Int AIDS Soc 2015; 18: 19918. Available at: https://dash.harvard.edu/bitstream/handle/1/17295521/4450241.pdf?sequence=1&isAllowed=y (accessed 30 May 2022).

3. Cuadros DF, de Oliveira T, Graf T, et al. The role of high-risk geographies in the perpetuation of the HIV epidemic in rural South Africa: A spatial molecular epidemiology study. PLOS Glob Pub Health [internet] 22 Feb 2022 https://doi.org/10.1371/journal.pgph.0000105 Available at: https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000105#sec017 (accessed 13 May 2022).

4. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS 2014; 11: e1001610. Available at: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001610 (accessed 4 June 2022).

2. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4.pdf (accessed 4 June 2022).


Covid-19 provides an opportunity to challenge lies about HIV in Africa


This website is about bloodborne HIV in Africa, not Covid-19 (hereafter: C19). However, because debates about C19 policies include charges of lies, misinformation, and unethical research, C19  debates have parallels with mismanagement of HIV in Africa. Recognizing these parallels could not only call attention to long-term mismanagement of HIV in Africa but also strengthen debates about C19. For example:

1. Government health agencies and critics charge each other with misinformation about C19 issues. Are health  agencies always reliable? Critics could strengthen their case by calling attention to decades of well-documented lies about HIV in Africa. For example:

Lying about bloodborne risks: For decades foreign and international public health agencies have assured Africans they won’t get HIV from health care even though the same agencies warned their employees they could get HIV from clinics serving the African general public (and arranged special, safe facilities for foreigners). All along evidence was available to show that bloodborne risks were a major contributor to Africa’s HIV epidemics (see Chapters 3 and 6 in [1]). We can quibble about the percentages of HIV from health care, but not about the lies and inadequate response to unexplained infections (no investigations to find and stop their source).

Lying that evidence shows sex accounts for most HIV-positive adults: Yes, evidence shows some adults got HIV from sex penile-vaginal sex. But evidence has never been available to show most infections come from sex. To the contrary: the best evidence says only a minority of HIV-positive Africans got it from sex (see Chapters 3 and 6 in [1]). The long-standing lie that most HIV in Africa comes from sex has led to millions of avoidable bloodborne infections, stigmatized HIV-positive adults with changes of sexual misbehavior, and endorsed long-standing racist stereotypes.

Lying to say Depo is safe: WHO and other public health agencies have lied to Africans about Depo-Provera injections for birth control, dismissing evidence they increase risk for women to get HIV by 40%-50% (for evidence and references, see menu on the right of this page).

2. Critics charge that the US National Institute of Health (NIH), Anthony Fauci, and Gates supported unethical research. These charges could be strengthened by noting long-term and repeated foreign support for unethical HIV-related research in Africa. For example (see also Appendix 2 in [1] or the menu on the right of this page):

Following HIV-positive adults who are unaware of their infections (but researchers know!) to watch them infect spouses, get sick, and die.

Following HIV-positive new mothers who are unaware of their infections (but researchers know!) to watch them infect their babies through breastfeeding.

Giving African women a drug known to increase their risk for HIV and following them to see how fast they get HIV.

Following and testing young African women twice per week in a community where young women get HIV at high rates to study immune responses to very new infections, but without identifying the sources of the new infections, which could protect women in the community.

Where are we going?

Critics of C19 policies challenge official C19 statements and recommendations. Are critics right or wrong? I expect time will tell. But in the meantime, debates  about C19 present an opportunity to recognize and challenge dangerous and demeaning HIV-related public health lies and unethical research afflicting Africans.

Is this a parallel?

After WWII, German Pastor Martin Niemoller confessed that his silence about early government abuses led to more widespread abuses[2]. Here’s a paraphrase of his famous confession – linking HIV lies to current C19 debates:

First they lied to Africans that they would not get HIV from healthcare, and we didn’t complain – because we didn’t take health care in Africa.

Then they followed HIV-positive Africans without telling them they were infected to watch infect their spouses and children, and we didn’t complain — because we didn’t live in Africa.

Then they didn’t warn African women about Depo injections increasing their risk to get HIV, and we didn’t complain -– because we didn’t live in Africa.

Then they asked people in rich countries to believe whatever they said about C19 – and who will help us challenge unreliable official data, analyses, and public health messages (behavior change communications)?

References

1. Gisselquist D. Stopping Bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available for free download at: https://sites.google.com/site/davidgisselquist/stoppingbloodbornehiv (accessed 28 January 2021).

2. Marcuse H. Martin Niemoller’s famous quotation: “first they came for the communists…” Niemoller Quotation Page [internet] 22 April 2021.  Available at: https://marcuse.faculty.history.ucsb.edu/niem.htm (accessed 18 December 2021). Niemoller’s confession: First they came for the socialists, and I did not speak out — because I was not a socialist. Then they came for the trade unionists, and I did not speak out — because I was not a trade unionist. Then they came for the Jews, and I did not speak out — because I was not a Jew. Then they came for me — and there was no one left to speak for me.

Please don’t bother me with facts, I like my sex fantasies!


Sex, sex, sex. Beginning in the late 1980s, several years after HIV was recognized in Africa, health bureaucrats, staff, and researchers have peddled salacious and racist fantasies that almost HIV-positive adults got it from sex.

But what about facts?

One way to see how people in a community have been getting HIV is to see who has viruses that are similar. Because HIV changes over time as it multiplies in anyone it infects, when two people are found to have very similar HIV (similar components in a similar order), one likely infected the other. Studies that look for people with similar HIV in African communities provide facts to test the fantasy that male-female sex accounts for almost all HIV-positive adults.

Here’s an example: During 2011-15, research staff drew blood from 25,882 people in 40 communities in Rakai District in Uganda.[1] More than 5,000 were HIV-positive. Researchers were able to describe HIVs (what components, what order) from 2,552 HIV-positive adults. Among the 2,552 HIV, researchers found 537 pairs with very similar HIV (“highly supported phylogenetic linkages”[page 5 in reference 1]), indicating that one person in the pair likely infected the other.

What do those pairs tell us about sexual fantasies?

1. Setting aside 176 spouse pairs with similar HIV (more on spouses below), there were 361 (=537-176) very similar non-spouse pairs. Here’s where the fantasy runs afoul of facts: 161 (45%) of those 361 non-spouse pairs were same-sex pairs, linking a man with a man, or a woman with a woman. Since the sex of whoever infected anyone seems to have been irrelevant (near equal numbers of same-sex pairs as male-female pairs), the obvious conclusion is that most transmission had nothing to do with sex. Most infections likely came from bloodborne risks such as unsterilized needles, syringes, catheters, saline bags, razors, lancets, etc., not from a sex partner. What about the 200 (=361-161) unmarried male-female pairs? Since the study says nothing about the sexual behavior of anyone in those non-spouse pairs, supposing sexual transmission is based on sex fantasy, not evidence.

2. What about spouses with similar HIV? The study collected and described HIV from 331 husband-wife couples. Only 176 (53%) of the 331 couples had similar HIV. Almost half of the couples (155 of 331) had non-matching HIV, which means husbands and wives likely got HIV from other blood or sex risks, not from their partners. In other words: Sexual transmission seems to be inefficient and slow in Africa as it is elsewhere in the world.

Instead of acting like scientist (respecting evidence), the research team that reported the above facts simply rejected same-sex pairs as mistakes: We don’t like the facts, so we ignore them! Let’s stick with sex fantasies! For example:

Example  1: In a 2021 sub-study, the research team used male-female pairs previously identified to fantasize about the ages of men and women having sex, ignoring same-sex pairs.[2] Because the average HIV-positive man is older than the average HIV-positive woman, one could expect pairs to include older men and younger women no matter how one infected the other (sex, or shared skin-piercing instruments). Duh! But the study team opted for sex fantasies: Hah, older men chasing younger women!  

Example 2: To estimate direction of HIV transmission between Rakai’s lakeshore communities and inland communities, the study team rejected 200 same-sex pairs as misleading (not agreeing with sex fantasies). Then, “[w]e further analysed the … male−female linkages to infer the direction of transmission”[page 6 in  reference 3]. Even so, what they found did not agree with sex fantasies – HIV was going from inland communities with lower percentages of adults infected to lakeshore communities with higher percentages infected. If it was going by sex, that doesn’t make a lot of sense – in sex partnerships across communities, the transmitting (HIV-positive) partner would more likely come from the lakeshore, where adults were more likely to be HIV-positive. On the other hand, if it were going by bloodborne risks in clinics and cosmetic services in inland communities along main roads, then the direction of transmission makes sense if, as seems likely, people from lakeshore communities visit facilities along major roads. Hence, it’s likely many male-female pairs were linked not by sex but by reused and unsterilized skin-piercing instruments.

Peddling sex fantasies about Africa’s HIV epidemic is not a victimless lie 

1. Sex fantasies distract everyone’s attention from bloodborne risks that people face in clinics and cosmetic services. That leads to infections.

2. Sex fantasies stigmatize HIV-positive Africans. Consider, for example, a woman who tests HIV-positive during antenatal care, and then her husband tests negative. Here’s what those who peddle sex fantasies are, in effect, saying to the husband: “Your wife had a boyfriend and lied about it!” What about a teenage boy or girl testing HIV-positive, or a husband? All slimed with abusive fantasies.

3. Health pros who push these fantasies suffer as well. If they know it’s a lie, how do they live with themselves? If they are too scared to investigate unexplained infections to find and stop unsafe practices in healthcare, how can they respect themselves and their profession?

References

1. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogeneetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4.pdf (accessed 13 December 2021).

2. Xi X, Spencer SEF, Hall M. Inferring the sources of HIV infection in Africa from deepsequence data with semi-parametric Bayesian Poisson flow models. arXiv [internet] 29 October 2021. Available at: https://arxiv.org/pdf/2110.12273.pdf (accessed 6 December 2021).

3. Ratmann O, Kagaayi J, Hall M, et al. Quantifying HIV transmission flow between high-prevalence hotspots and surrounding communities: a population-based study in Rakai, Uganda. Lancet HIV 2020; 7: e173-e183. Available at: https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC7167508/ (accessed 13 December 2021).