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Category Archives: HIV

HIV Risks: Greed and Officialdom


It’s refreshing to experience a work of drama that describes a HIV outbreak which occurs in a healthcare setting, without a hint of the prurience that is so common in most accounts of the subjects of HIV and Aids. The play closes tomorrow in the Hampstead Theatre in London (review).

The King of Hell’s Palace tells the story of Dr Shuping Wang, who risked her life, and the safety of her family and friends, to raise awareness of exceptionally high rates of HIV transmission in Henan Province, China, in the 1990s. These were evidently a result of unsafe practices in plasma donation programs, which were a source of income for hundreds of thousands of people in the province.

Estimates of how many people were infected with HIV and hepatitis C through these programs vary, from 10s of thousands to hundreds of thousands, and it’s impossible to say how many were infected. It’s also likely that many of those infected by the plasma programs went on to infect others, directly and indirectly.

Dr Shuping Wang succeeded in closing down the plasma donation programs. Safety procedures were put in place before they were allowed to restart. An awful lot of damage was done, and those who were benefiting most from the programs were reluctant to see their source of income threatened. But the efforts of one person undoubtedly saved hundreds of thousands of people, perhaps millions.

Most people who watch movies will have seen movies that have been made about HIV and Aids. But the bulk of them are about HIV transmission among men who have sex with men. Some bring in injected drug use, and some include transmission among heterosexuals, especially where sex workers are involved.

However, most HIV positive people in the world are not sex workers, they are not men who have sex with men, they don’t inject drugs and most of them are certainly not white people from wealthy countries.

The majority of HIV positive people live in certain parts of certain sub-Saharan African countries. In other words, they are not distributed evenly among populations, as you might expect of a virus that is, according to the HIV industry, almost always transmitted via ‘unsafe’ sex.

Most people in all countries in the world, African countries included (surveys of sexual and other behaviors), do not engage in the very high levels of ‘unsafe’ sex that would be required to account for massive outbreaks that are found in countries such as South Africa, Botswana, Eswatini (Swaziland) and Lesotho.

Some people in all countries in the world do engage in high levels of ‘unsafe’ sex, but most do not. In fact, even among sex workers in wealthier countries, HIV prevalence is low unless they also have other risks, such as injecting drugs.

What you do find in African countries is unsafe healthcare, badly trained healthcare professionals, quacks and low skilled practitioners who pass themselves off as doctors, nurses and midwives, dispensaries that will give you anything if they can make money out of it, including injections of things you don’t need, and that may do more harm than good.

And yet there has never been a single investigation in sub-Saharan Africa of the kind that closed down the unsafe plasma programs in China in the 90s. There were investigations in Pakistan (still going on), Cambodia, Libya, Russia, Tajikistan and a number of other countries (list of countries which have and have not responded to outbreaks).

The Chinese administration officials in 1990s Henan Province are depicted as greedy, and as being unwilling to risk losing their job and reputation, even though they knew that Dr Suping Wang was right; they were infecting countless people with deadly pathogens just so they could cash in on the demand for plasma.

Similarly, there are officials in UNAIDS and other UN offices, such as the WHO, officials in the CDC, various country administrations in high HIV prevalence countries, academics all over the world and even journalists who see themselves as having a role in highlighting serious injustices; why are they not calling for investigations into outbreaks that affect more than half of young women in some towns in South Africa, Western Kenya, parts of Tanzania, Mozambique and Malawi?

There have been protests and movements demanding rights for men who have sex with men, transsexuals, and others in wealthy countries, where the majority of HIV positive people fall into those groups.

But where the majority of HIV positive people are black, and they are neither men who have sex with men nor injecting drug users (HIV positive females outnumber HIV positive males in high prevalence countries), there are no protests.

About 70% of HIV positive people live in sub-Saharan Africa and over 70% of HIV positive people in the region live in certain towns and cities in just a handful of countries: that’s where the investigations need to be carried out. Surely, no one’s interest is served by continuing to insist that HIV prevalence is high in a few places just because of ‘African’ sexual behaviour?

Can UK Tattoo Artists Guarantee the Safety of their Services?


Apparently some tattoo studios in the UK suggest that they can’t, because they have refused to allow HIV positive people to get tattoos. Legally, they are not allowed to ask their clients to reveal their HIV status. But if they are worried that tattoo artists themselves, or their HIV negative clients, risk being infected if they accept HIV positive clients, they must believe that the precautions they take to avoid transmitting pathogens are not adequate.

The Vice article linked to above mentions the possibility that people who don’t know they are HIV positive may choose to get tattoos or body piercing, which is important. But there are also risks of other serious pathogens, such as hepatitis C, being transmitted. The Vice article concentrates on HIV positive people being discriminated against; but a much more important issue is whether anyone’s safety is guaranteed when they get a tattoo, body piercing or any skin piercing procedure.

Tattoos and body piercing are not the only cosmetic procedures that carry risks of transmitting bloodborne pathogens. It is now possible to get injectable steroids, tanning products, botox and other things that are administered by skin piercing tools, such as syringes, needles, lances and the like. You can order these products online, to be sent to your home, and get them at certain clinics and service providers. So they could be administered by people with little training, or even none at all; people can self-administer them and/or administer them to friends.

Anything that pierces the skin can carry a risk. Sometimes the risk is small, but sharing injecting and other skin piercing equipment can carry a very high risk. Someone else’s blood should never come in contact with yours unless you’re getting a blood transfusion, and your blood should never come in contact with someone else’s.

These incidents outlined by Vice highlight that the complainants have been denied their right to confidentiality, and would be discriminated against for revealing that they are HIV positive. But it also highlights the fact that people providing any cosmetic services that may involve breaking the skin do not all have adequate knowledge about skin piercing and dangerous pathogens. These procedures could even include manicures, pedicures, shaving and hair-styling,

Vice reports one person working at a clinic as saying “Well, if someone has HIV we take extra precautions, especially if they have cuts or broken skin”. But tattooing, piercing, etc, involve cutting/breaking skin, by definition. The very reason they should be taking precautions is because what they do breaks skin!

People providing such services should already ensure that they do not reuse unsterilized instruments, including machinery, paints and anything else that may lead to transmission of a pathogen. No pathogen whatsoever from one client should come in contact with another client, or with the person providing the services.

If service providers do not already take these precautions they should be closed down, and all their clients should be checked for bloodborne pathogens. If they believe they need to, or even believe that can take additional precautions just because their client is HIV positive, they should not be not be providing those services.

HIV: A British Colonial Hangover?


Data Source: UNAIDS

Despite continued claims that the vast majority of cases of HIV transmission in sub-Saharan Africa are a result of heterosexual sex, no clear explanation has been given for the substantial heterogeneity at the national and subnational levels.

In other words, what is so different about sexual behaviour in Morocco, where HIV prevalence is less than 0.1%, and that in Eswatini (Swaziland), where it is 27.2%, 272 times higher?

As an example at the subnational level, what is so different about sexual behaviour in the Kenyan county of Wajir, where prevalence is less than 0.1% and the county of Siaya, where prevalence is 21.0%, over 200 times higher?

Petabytes of data have been collected about sexual behaviour all over the world. Everywhere, some people have a lot of sex, some people have little or none and the rest are somewhere in between. But few useful correlations between heterosexual behaviour and HIV transmission have been found, at national or sub-national levels.

At the national level, the majority of the highest prevalence countries, and the countries with the largest number of people living with HIV are former British colonies. Prevalence ranges from 0.1% (Egypt) to 27.2% (Eswatini), with a median of 6.5% (Uganda).

Data Source: UNAIDS

In contrast, the range in former non-British colonies is 0.1% (Algeria and Tunisia) to 12.4% (Namibia). The median is about 1.5%. A third of these countries have prevalence figures of 1% or below. Less than one third of people living with HIV live in former non-British colonies.

Data Source: UNAIDS

The copious quantities of sexual behavior data referred to above confirm that the British did not introduce a liberal or enlightened attitude towards sex, nor did they promulgate forms of ‘risky’ sexual behaviour not found in French or Belgian colonies. So there must be something unrelated to sex involved, right?

Although modes of HIV transmission have been identified, it seems likely that the contribution of non-sexual transmission via unsafe healthcare and other skin-piercing processes in sub-Saharan African countries has been seriously underestimated by UNAIDS and the other recipients of massive HIV funding.

Currently, people in sub-Saharan Africa receive incessant warnings about sexual risks, with non-sexual risks through unsafe healthcare and other skin-piercing processes dismissed as minor. And although risks of bloodborne infection, especially in healthcare facilities, were identified and addressed in wealthier countries from the 1980s, there have been many outbreaks in poorer countries later shown to be a result of unsafe healthcare.

There are examples of bloodborne HIV outbreaks that have been investigated and confirmed to have been a result of unsafe healthcare. One in Ratodero, Pakistan, is currently being investigated. There was a recent one in Roka Commune in Cambodia that was also investigated. Outbreaks in Romania, China and other countries received international press attention.

However, no bloodborne outbreaks in sub-Saharan Africa have been investigated. Instances that should have been seen as possible bloodborne outbreaks have been ignored. But lurking in the history of healthcare development and practices in Africa, both pre- and post-independence, may be a clue as to why HIV should be so prevalent in former British colonies.

Will women who got HIV during the ECHO trial sue for damages?


The ECHO trial (Evidence for Contraceptive Options and HIV Outcomes) was both unethical and useless by design. The trial, reported June 2019, compared three birth control techniques: Depo-Provera (DMPA-IM) injections every three months, an IUD (intrauterine device), and levonorgestrel implants.[1]

  • Research to date has shown that Depo-Provera increases women’s risks to get HIV by 40%-50%.[2,3] By randomizing women to Depo-Provera, the trial violated articles 3, 4, and 9 of the World Medical Association’s Declaration of Helsinki on research ethics (eg, article 9: “It is the duty of physicians who are involved in medical research to protect the life [and] health…of research subjects).”[4]
  • Research to date has shown that birth control pills do not increase women’s risk for HIV.[2,3] By not including birth control pills among the contraceptive methods in the trial, the study violated article 33 of the Declaration of Helsinki (“The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best proven intervention(s)…”).[4]

ECHO trial results have been widely misinterpreted. A report of the trial in The New York Times, for example, said the results show Depo-Provera “does not raise HIV risk.” Because the trial did not compare Depo-Provera to pills, it does not support that statement.[5]

The ECHO trial could have been both ethical and useful if it had compared birth control options for which there is limited evidence of their impact on women’s HIV risk (eg, IUDs, levonorgestrel implants, and monthly injections of norethisterone enanthate) to birth control pills, for which there is good evidence of little or no impact on women’s HIV risk.[2,3]

As it is, the trial suggests IUDs and levonorgestrel implants likely increase women’s risk for HIV less than does Depo-Provera, if at all. But how did women get HIV: from sex or skin-piercing health care procedures?[6] In countries where skin-piercing health care instruments are unreliably sterile, knowing how women got HIV is relevant for advising them about how to avoid HIV from health care, including skin-piercing birth control options.

Limited information on sexual risks for women in the trial suggests sex caused far less than half of new HIV infections during the trial. During quarterly follow-up visits, 49% of women reported more than 10 sex acts in the previous three months; to err on the high side, I assume all women averaged 15 sex acts per quarter or 60 per year. Fifty-five percent reported no condom use during their last sex act (see Table S11 in [1]). From this I estimate an average of 33 (= 55% x 60) unprotected sex acts per year for all women. I assume 25% of partners were HIV-positive. Using a transmission efficiency of 0.12 per 100 sex acts (from a study in Uganda[7]) I estimate women got HIV from sex at the rate of 1%/year (= 33 unprotected sex acts/year x 25% with an HIV-positive partner x 0.0012 transmissions per HIV-exposed sex act). This is far less than the observed 3.8%/year rate of new infections.[1]

Like many other studies in high-prevalence areas in Africa, the study withholds collected data relevant to assess sexual and non-sexual risks. Encouragingly, the study tested partners for HIV (pp 305-6 in [1]), following recent WHO advice.[8] But the study does not say how many partners tested HIV-positive or how much having an HIV-positive partner increased a woman’s HIV risk. The study does not report if women who got HIV during follow-up intervals reported any sex acts — with or without HIV-positive partners — during those intervals. This, too, violates the Declaration of Helsinki (article 36: “Researchers have a duty to make publicly available the results of their research on human subjects and are accountable for the completeness and accuracy of their reports…”).[4]

Aside from not reporting all relevant collected information, by all accounts the study did not collect other relevant information. Like most other foreign-funded HIV research in Africa, the study ignored non-sexual risks. not trace and test partners.

Unethical research funded from rich countries has harmed people in less developed countries for decades. The ECHO trial had no problem finding health care professionals willing to do the dirty work and no problem getting ethical approval: more than 750 people collaborated in ECHO research and 13 review boards approved it (supplementary appendix in [1]).

How to stop these outrages? Appealing to courts may get better results than waiting for health care professionals to change. Recently, a United States’ (US) court allowed Guatemalans harmed during medical research to sue private US institutions in US courts.[9] Does this mean that any woman in the ECHO trial randomized to Depo-Provera who got HIV during the trial could sue private US institutions involved in the trial in US courts?

References

1. Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 2019; published online June 13. Available at: ht; tp://dx.doi.org/10.1016/S0140-6736(19)31288-7; supplementary appendix availabe at: http://echo-consortium.com/wp-content/uploads/2019/06/ECHO-primary-HIV-results-appendix-Lancet-online-first-June-2019.pdf (accessed 28 July 2019)

2. Morrison CS, Chen PL, Kwok C, et al. Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis. PLoS Med 2015; 12: e1001778. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303292/ (accessed 26 July 2019).

3. Polis CB, Curtis KM, Hannaford PC, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016; 30: 2665–83. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106090/ (accessed 26 July 2019).

4. World Medical Association (WMA). Declaration of Helsinki – ethical principles for medical research involving human subjects. New York: WMA, 1964, revised 2013. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ (accessed 26 July 2019).

5. McNeil DG. Depo-Provera, an injectable contraceptive, does not raise HIV risk. New York Times 13 June 2019. Available at: https://www.nytimes.com/2019/06/13/health/depo-provera-hiv-africa.html (accessed 27 July 2019).

6. Gisselquist D. Advice to Young Women in Africa: Sex May Not Be Your Biggest Risk for HIV. SSRN, posted 1 May 2019. Available at SSRN: https://ssrn.com/abstract=3381252 (accessed 28 July 2019)

7. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis 2005; 191: 1403-1409. Available at: https://academic.oup.com/jid/article/191/9/1403/860169 (accessed 26 July 2019).

8. WHO. Guidelines on self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: WHO, 2016. Available at: https://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/en/ (accessed 26 July 2019).

9. Stempel J. Johns Hopkins, Bristol-Myers to face $1 billion syphilis infections suit. Reuters 4 January 2019. Available at: https://www.reuters.com/article/us-maryland-lawsuit-infections/johns-hopkins-bristol-myers-must-face-1-billion-syphilis-infections-suit-idUSKCN1OY1N3 (accessed 26 July 2019).

 

 

Government of Pakistan protects patients. African governments don’t. Why not?


On 21 July 2019, at an international HIV/AIDS conference in Mexico, Farima Mir reported an ongoing investigation in Ratodero, Pakistan, that has found hundreds of children with HIV from healthcare[1]:

“At the end of April, 46 children in the city tested positive for HIV. And within 2 days, 14 more children were reported in nearby towns. The government mounted a response, screening around 32,000 people… Ultimately, over 770 of the 997 reported new infections were in young children, most from ages 2 to 5 years… Mir said that almost all children who tested positive for HIV had ‘repeated injections for any illness,’ meaning reused syringes were likely to blame.”

What happened in Pakistan echoes what has been found elsewhere, for example, Russia in 1988, Romania in 1989, Libya in 1998, etc (for more information about these and other HIV outbreaks from health care click on “outbreaks and unexpected infections” in the menu at the right of this page).

Almost surely there are many similar outbreaks of HIV from reused and unsterilized syringes, needles, razors, needles and tubes for infusions, and other health care instruments in African countries with the world’s worst HIV epidemics. But no government in sub-Saharan Africa has looked to find and stop HIV from unsafe health care! Whereas Government of Pakistan protects people by investigating unexpected HIV infections, governments of sub-Saharan Africa stick their heads in the sand. How many more people will get HIV from health care in Africa before governments investigate unexpected infections to find and stop the problem?

References

1. Walker M. ‘Man-Made Disasters’ Stymie Progress on Global HIV. Medpage Today 22 July 2019. Available at: https://www.medpagetoday.com/meetingcoverage/ias/81150 (accessed 23 July 2019).

Let’s stop HIV in Africa. What are you waiting for?


Question for African governments: Why haven’t you investigated unexplained HIV infections?

Question for CDC, UNAIDS, WHO: How can you say you want health care to be safe in Africa, but then NOT challenge governments to investigate unexplained infections?

Questions for people living in African: Do you know anyone who is HIV-positive who denies sexual risks? Do you believe them? Have you heard of a child with HIV but with an HIV-negative mother? If they got HIV from health care, you and your loved ones are also at risk. When are you going to ask your government to investigate unexplained infections to find and stop any hospital or clinic that has been infecting patients?

Question for researchers: Why haven’t you tried to find out how people got HIV: trace and test partners: ask where people got skin-piercing treatments?

Question for anyone: Why do you accept racist, sexual fantasies to explain Africa’s HIV epidemics? Yes, sex is a personal risk for HIV, but what is different in Africa that could explain Africa’s terrible HIV epidemics is not sexual behavior but unreliably sterile injections, infusions, and other health care procedures.

Hundreds of children in Pakistan infected by HIV from health care; government investigates to protect children


Beginning end-April 2019, government of Pakistan has been investigating an outbreak of HIV from unsafe health care in Ratodero county. As part of the investigation, government set up camps to test people for HIV. As of 23 May, tests on 20,800 people in Ratodero found >608 to be infected, including >500 children.[1] Almost all HIV-infected children had HIV-negative mothers. 

According to a recent report[2]: “Adviser to the Prime Minister for Health Dr. Zafar Mirza has said that outbreak of HIV in Ratodero has not only shaken the country but entire world adding when he was in Geneva he was also asked about surfacing of HIV… He said root cause of large number of children must be detected… He said federal government along with UNICEF, WHO, UNAID, Aga Khan, Aga Khan University Hospital and other organizations is cooperating with the Sindh government in this connection and they will continue to coordinate till root cause is detected, he added.”

In sub-Saharan Africa, children get HIV from unsafe healthcare, but no government has investigated to protect them

Lots of HIV-positive children with HIV-negative mothers are reported in Africa, but unlike Pakistan, no government has investigated. Nor have WHO or UNAIDS advocated any investigation. Here are some of the many reports of HIV-positive children in Africa with HIV-negative mothers:

* Mozambique, 2015: A random sample national survey found 30 HIV-positive children aged 6-23 months; 10 (33%) of the 30 children had mothers who were HIV-negative.[3]

* Uganda, 2011: A random sample national survey tested adults and children aged 0-5 years for HIV. Based on reports from this survey,[4] an estimated 17% (12 of 70) HIV positive children had mothers who tested HIV-negative (click on “outbreaks and unexpected infections” and then “Uganda” country page).

* Mozambique, 2009: A random sample national survey in 2009 tested children as well as adults for HIV. The study found 63 HIV-positive children aged 0-11 years old, of which 18 (29%) had mothers who tested HIV-negative.[5,6]

* Swaziland, 2006-7: A random sample national survey tested 1,665 mother-child pairs with children aged 2-12 years. Fifty children were infected; 11 (22%) of their mothers tested HIV-negative.[7,8]

WHO’s double standard

WHO’s double standard goes back decades. For example, during 1990-93, WHO’s Global Programme on AIDS coordinated studies in four African countries – Kigali, Rwanda; Kampala, Uganda; Dar es Salaam, Tanzania; and Lusaka, Zambia – to test inpatient children and their mothers for HIV infection. Combining data from the four cities, 61 (1.1 percent) of 5,593 children aged 6-59 months were HIV-positive with HIV-negative mothers.[9] Only three children had been transfused. Although these infections suggested a lot of HIV transmission through unsafe healthcare, WHO, incredibly concluded ‘the risk of…patient-to-patient transmission of HIV among children in health care settings is low.’[10]

At least WHO in 2019 is acting to protect children in Pakistan from getting HIV from unsafe healthcare. Will this ongoing investigation lead WHO to change its long-standing policy of neglect in Africa?

References

1. Masood T. Situationer: dealing with HIV outbreak among children. Dawn 23 May 2019. Available at: https://www.dawn.com/news/1483999 (accessed 24 May 2019).

2. Dawoodpoto J. “HIV in Ratodero has not only shaken the country but entire world.“ Daily Times 24 May 2019. Available at: https://dailytimes.com.pk/399789/hiv-in-ratodero-has-not-only-shaken-the-country-but-entire-world/ (accessed 24 May 2019).

3. page 231 in: Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), e ICF, 2015. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. Rockville, Maryland: ICF, 2018. Available at: https://dhsprogram.com/pubs/pdf/AIS12/AIS12.pdf

4. Table 8.13 in: Uganda Ministry of Health, and ICF International. Uganda AIDS Indicator Survey (UAIS) 2011. Calverton: ICF International, 2012. Available at: https://dhsprogram.com/publications/publication-AIS10-AIS-Final-Reports.cfm(accessed 6 December 2018).

5. pp. 177-181 in: INS, INE, and ICF Macro. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. Calverton, Maryland: ICF Macro, 2010. Available at: http://measuredhs.com/pubs/pdf/AIS8/AIS8.pdf (accessed 19 January 2012).

6. Brewer D. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. Webmedcentral 2011, Article ID WMC002206. Available at: http://www.webmedcentral.com/article_view/2206(accessed 19 January 2012).

7. CSO, eSwatini, and Macro Int. Swaziland Demographic and Health Survey 2006-07. Mbabane, Swaziland: CSO and Macro International, 2008. Available at:  https://dhsprogram.com/pubs/pdf/FR202/FR202.pdf (accessed 8 November 2018).

8. Okinyi M, Brewer DD, Potterat JJ. Horizontally acquired HIV infection in Kenyan and Swazi children. Int J STD AIDS 2009; 20: 852-857. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19948900(accessed 27 October 2018); article available at: http://www.interscientific.net/IJSA2009Okinyi.html (accessed 15 October 2018).

9. Hitimana D, Luo-Mutti C, Madraa B, et al. ‘A multicentre matched case control study of possible nosocomial HIV-1 transmission in infants and children in developing countries’, 9thInt Conf AIDS, Berlin 6-11 June 1993. Abstract no. WS-C13-2.

10. Global Programme on AIDS. 1992-1993 Progress Report, Global Programme on AIDS. Geneva: WHO, 1993. p. 85.

Antimicrobial Resistance and PrEP: Medical Disasters


Here are two antimicrobial resistance (AMR) scenarios, one rapidly spiraling out of control, and the other (arguably) incipient:

The AMR scenario that is spiraling out of control is described in an article in The New York Times. The development of AMR is blamed on overuse and misuse of cheap antibiotics, usually without prescription. Ever-increasing use and misuse of antibiotics results in ever-increasing development of resistant strains of pathogens.

The NYT article describes the appalling conditions that an estimated one billion people live in; slums where waterborne, foodborne and airborne pathogens thrive. Unable to escape the risks, people try to treat the symptoms with antibiotics, inevitably leading to resistance to most or all available treatments.

The scenario described is a loop: widespread disease leads to overuse of antimicrobials; this leads to development of resistance; people with resistant conditions, if they survive, are taken to healthcare facilities, which also overuse antimicrobials, amplifying resistance and transmission of resistant strains; this loops back to the slum, resulting in an even higher disease burden, and greater levels of resistance.

The loop could be broken by: 1) improving the environment, including water, sanitation, habitation, food, etc and 2) improving conditions in healthcare facilities, infection control, safety, hygiene, etc. This will reduce antimicrobial use and, therefore, resistance.

The approach suggested by the Global AMR R&D Hub, on the other hand, risks speeding up the loop leading to AMR. They aim to “tackle the threat of resistant pathogens” by developing “new antibiotics and treatments against infections.” Producing antimicrobials of ever-increasing power, without addressing 1 and 2, above, only continues the cycle of ever-increasing resistance.

The other scenario is described on websites such as iwantprepnow.co.uk (and prepster.info and others). They advise on the use of PrEP (pre-exposure prophylaxis), antiretrovirals taken by HIV negative people to reduce the risk of HIV infection. For example, if “you have sex in a variety of situations where condoms are not easily used or not always used”, PrEP, if properly used, can reduce risk of infection with HIV by more than 90%.

There are (at least) two problems with this. Firstly, overuse or incorrect use of antiretrovirals can give rise to a resistant strain of HIV developing in an infected person, and that resistant strain can also be transmitted to others.

Secondly, the advice from iwantprepnow.co.uk (and other similar sites, such as PrEPster.info) is aimed at people who frequently have sex without protection from other sexually transmitted infections (STIs). Exposing yourself repeatedly to infection with STIs increases the development of resistant strains of, for example, gonorrhea, shigella and Mycoplasma genitalium.

Use of PrEP without condoms also increases transmission of hepatitis C virus: “Incidence of acute hepatitis C virus (HCV) among men who have sex with men who use PrEP in Lyon increased tenfold between 2016 and 2017”. HCV has doubled among HIV positive people.

The Center for Strategic and International Studies spectacularly fail to notice the positive feedback mechanism, whereby improper use of PrEP could increase transmission of STIs and the development of resistance in countries where HIV prevalence is highest, sub-Saharan African countries:

“In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin.” The same article even acknowledges that “High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition”, without noticing how PrEP will increase STIs and resistance!

According to The WHO, health is a “State of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” In the two AMR scenarios described above, producing stronger antimicrobials and PrEP are examples of medicalization of health, viewing it as merely the absence of disease or infirmity. These kinds of medicalization will radically increase AMR.

Cherie Blair and ‘Rape in Africa’ Stereotypes


Cherie Blair was accused of perpetuating and reinforcing stereotypes and usurping African voices with her comment that “most African ladies’ first sexual experience is rape”. The English Guardian and NPR both weigh in, with a number of reasons why Blair’s remarks were met with outrage.

Critics of Blair are not wrong in calling her out on these comments. But they don’t go far enough. Yes, Blair should have acknowledged, for example, that rape and gender based violence are faced by women everywhere, not just in African countries. But Blair is only repeating stereotypes she would find throughout the mainstream media, and in a lot of specialized published sources.

Blair is far from being alone in perpetuating and reinforcing stereotypes, such as those of the ‘promiscuous African’, ‘the violent African male’, ‘the widespread exchange of sex for money’, ‘the disempowered African female’, etc. Most of these stereotypes are a lot older than Blair, and date back to colonial times, at least.

Nor have the long-held stereotypes mellowed with age. The bulk of HIV programming (and spending) is based on the very assumption that “sexual transmission [is] the major mode of spread of HIV-1 in Africa”, with some estimates suggesting that sex accounts for 80-90% of all transmissions in high prevalence countries (which are all in sub-Saharan Africa).

On the subject of rape, the Center for Strategic and International Studies (CSIS) claims that: “Girls and women [in South Africa] also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.”

CSIS was commenting on the fact that in some parts of South Africa, 60% of women are HIV positive. Many new infections are among girls 15-24 years old. However, the entire CSIS article assumes, without ever arguing for it, that all HIV transmission is sexual. This assumption may suggest that stereotypes such as those above are based on empirical findings, rather than being rank prejudice.

Far from being based on research, stereotypes about ‘African’ sexual behavior are flatly contradicted by vast quantities of data collected by Demographic and Health Surveys, every five years, about sexual behavior in African countries. Just select any sub-Saharan country; rates of ‘unsafe’ sexual behavior are low, and there is little or no correlation with HIV prevalence.

Cherie Blair is unlikely to have come across views that diverge from the mainstream prejudices about HIV in SSA, and that challenge those prejudices. But many of those challenges can be found, for example, in a paper by John Potterat, and in the bibliography for that paper. One of the main suspects in high rates of HIV transmission is unsafe healthcare; others are unsafe cosmetic and traditional practices.

If Blair would like to reconsider the sort of stereotypes about sexual behavior and violence also expressed in the CSIS article, this is a good time to do so. Those outraged by her comments about ‘Africans’ and their alleged sexual behavior may wish to avail of the same research. Otherwise they all risk reinforcing and perpetuating stereotypes.

Ebola: A Strategy of Misinformation?


In an article in The New England Journal of Medicine entitled ‘An Epidemic of Suspicion — Ebola and Violence in the DRC’ Vinh-Kim Nguyen writes about violent attacks on Ebola treatment units and other health facilities. Nguyen argues that: “Epidemics thrive on fear — when they are frightened, patients flee hospitals, sick people stay away to begin with, and affected communities distrust groups trying to respond to the epidemic.”

But there’s an important sense in which the opposite may be true. When people fear something that has proven dangerous in the past, avoiding that something may be the only rational response, the only way to avoid the danger. After all, several well-documented epidemics have been shown to thrive on unsafe healthcare. Examples are Ebola Virus Disease (EVD), hepatitis C (HCV), extensively drug resistant tuberculosis (XDR TB) and MRSA (Methicillin-resistant Staphylococcus aureus).

The second ever outbreak of EBV, which occurred in Yambuku (in Zaire) in 1976, was a result of unsafe healthcare: “Peter Piot…concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes.”

WHO has recently announced that “The outbreak [of EBD] in Katwa and Butembo health zones [in DRC] is partly being driven by nosocomial [=originating in a hospital] transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission.”

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people…. [T]he wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs. A significant healthcare associated outbreak occurred in Egypt in the 1970s.

Associated with poor infection control in health facilities, one of the first outbreaks of XDR-TB was discovered in Tugela Ferry Hospital, KZN, South Africa, in 2005. And a significant proportion of healthcare associated infections are resistant to methicillin (ie, MRSA).

Nguyen goes on: “In areas where the epidemic response has not involved security forces…people ask to be vaccinated.”

But rolling out vaccinations in environments where infection control is inadequate (for example, healthcare facilities) might increase the risk of viral strains developing resistance (for example, among healthcare practitioners). Going to a healthcare facility during an outbreak of Ebola may be the worst thing a person can do. When people didn’t go to health facilities during earlier outbreaks, case numbers were limited, and the outbreak didn’t last long.

Nguyen has also highlighted the importance of trust, and the consequences of mistrust of authority, experts and science. But if people are right to question the safety of healthcare facilities, as it would appear from above considerations, how can the trust of people at risk of exposure to ebola and other pathogens be regained?

As long as continued Ebola transmission is blamed on what is depicted as an irrational fear of healthcare and vaccinations, people will stay away from healthcare. Because their fear is far from irrational, it is supported by scholarly research, expert opinion and even communications from the WHO. XDR TB, MRSA, HCV and other outbreaks have been shown to be healthcare associated outbreaks. Healthcare facilities also contribute the lion’s share to anti-microbial resistance (AMR).

Modern healthcare facilities are potentially dangerous places. If patients were informed about the dangers, they would know better how to avoid them, and healthcare facilities would be compelled to address those dangers. Some of the earliest EBV outbreaks occurred when people came together around healthcare facilities, and died out when healthcare facilities closed, often because healthcare staff had been wiped out by Ebola.

Trust in healthcare in developing countries may be regained, slowly, if people are adequately informed about the greatest risks they face, such as poor infection control, lack of hygiene, AMR, etc. Trust will not be regained by dreaming up new misinformation, nor by reinforcing old misinformation.