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Category Archives: nosocomial

Via Negativa and ‘First do no Harm’


I am in favor of routine vaccination, for my children and for children in my care. I always take children to a doctor when there is something that won’t go away on its own, or that I don’t recognize, and I would do the same for myself. So I am certainly not advocating ‘doing nothing’ as a response to medical problems. I write as a layperson, with an interest in healthcare and development.

But all healthcare must also be safe healthcare; people should be granted their right to know everything they need to know in order to make the best choices for themselves and their dependents, in accordance with the Lisbon Declaration on the Rights of the Patient, along with other instruments relating to patient safety. I feel that people, especially in developing countries, are frequently denied these rights, and that the results of this can be fatal.

In his guest post for this blog, Helmut Jager discusses the example of the infection of millions of Egyptians with hepatitis C (HCV) through unsafe healthcare, resulting in the highest prevalence of the virus in the world. Jager states that the “causes of the infections [globally] mostly are: bad medicine or intravenous drug addiction”.

The ‘bad’ medicine Jager refers to is a program intended to reduce infection with schistosomiasis (bilharzia), caused by a waterborne parasite. This program involved the use of syringes, needles and perhaps other equipment that were not always sterile. Under such conditions bloodborne pathogens, in this case, HCV, can be transmitted from patient to patient.

The medicine Jager describes is ‘bad’ because conditions in healthcare facilities are unsafe, instruments are being reused without adequate sterilization, etc. Rising numbers of people with HCV in the population eventually visiting health facilities meant increasing numbers of healthcare associated transmissions, also called ‘iatrogenic’; a vicious cycle.

Jager is not suggesting that healthcare facilities should do nothing about schistosomiasis (or any other condition) in order to avoid the risk of iatrogenic transmission of HCV or other bloodborne pathogens. He is recommending that unsafe practices be eradicated, practices such as the reuse of injecting and other equipment and processes that involve piercing the skin, or even come in contact with bodily fluids, such as speculums, gloves, etc.

Reducing unnecessary medicine is another of Jager’s recommendations. The WHO estimates that 16 billion injections are administered globally every year. In some countries up to 70% are probably unnecessary. About 37% were said to involve reused injecting equipment. Therefore, reuse of other skin-piercing equipment may also add substantially to the problem.

Jager’s blog is about the high cost of Gilead’s ‘sofosbuvir’ and the damage this does to programs aimed at eradicating the virus. Sofosbuvir has been recommended by the WHO for the treatment of HCV: it is unaffordable for people in poor countries, who make up the bulk of those living with the virus, at risk of suffering serious illness from it, and of dying from it. Jager cites a source reporting that “treatment costs in the US are US$84,000 and in the Netherlands €46,000. The production cost of the drug is estimated not to exceed US$140.”

There are two man-made disasters here: first, there’s the raising of the Aswan Dam in the 1960s. The dam was intended to control the flow of the Nile in order to improve irrigation provision and generate hydroelectricity; this damaged ecosystems and led to an increase in schistosoma infestations. The second was the massive outbreak of HCV caused by unsafe healthcare procedures, employed to address the schistosomiasis endemicity, that affected millions of people.

Apparently environmental impact assessments evolved in the 1960s, but it is likely there was something similar before the specific phrase was adopted. After all, it was known that introducing invasive species of fish to Lake Victoria would cause huge and irreversible problems early in the last century; the invasive species were introduced anyway, because certain parties wanted them to be (the colonials wanted to introduce sport fishing to the lake for their enjoyment). The fragility of ecologies has been recognized for a long time.

Whether either or both these disasters could have been avoided 50 or more years ago, strategies to eradicate schistosomiasis sometimes seem to concentrate on a quick technical fix (there’s even a vaccine in development now), such as mass administration of Praziquantel. Praziquantel works, up to a point. It cures patients, and reduces the infected population, which promotes herd immunity and helps interrupt the life cycle of the parasite. But it is less effective in eradicating the parasite when used on its own.

Research in Lake Victoria finds that the population affected by schistosomiasis also needs access to safe drinking and domestic water supplies, reduced contact with contaminated water, adequate waste disposal (which can interrupt the life cycle of the parasite), etc. In other words, the first disaster Jager alludes to, schistosoma infestation in the waterways, affects a much larger population than those who live close to and depend on the waters of the Nile.

This is a larger and more general problem, because all massive infrastructure projects risk destroying ecosystems and environments. And the medical treatment people need once their water supply is infested can be too little; but possibly not too late. It’s too little because those affected will still need access to safe water and sanitation, but some of these issues can be addressed, bearing in mind the counsel of ‘first, do no harm’.

Water and sanitation provision is vital, as is promotion of good health related information. Gilead are unlikely to scale back their profits much unless they are compelled to do so; yet, intervention would not be unprecedented. Unsafe healthcare can be eradicated, much more cheaply and efficiently than mopping up the victims of unsafe healthcare. And unnecessary healthcare can also be reduced, substantially, which will further reduce unsafe healthcare.

In my previous post I speculated that counties in Kenya with very low HIV prevalence, such as Wajir, Garissa and Mandera, may have escaped high levels of transmission through unsafe healthcare by having very low levels of healthcare provision of any kind. I also speculated that high HIV prevalence in counties such as Homa Bay, Kisumu, Siaya and Migori may be a result of greater access to healthcare facilities and health programs whose practices are not particularly safe.

So those four counties on the shores of Lake Victoria, with fishing as one of the most important activities, must have very high rates of intestinal parasites (and other conditions; Eileen Stillwaggon sets out this argument in Aids and the Ecology of Poverty). If use of health facilities is high, the chances of a pathogen such as HIV contaminating medical equipment, which is then reused without adequate sterilization, must also be high.

Where healthcare is unsafe, carrying the risk of exposure to bloodborne pathogens, such as HCV, HIV and others through reuse of skin-piercing instruments, it’s best avoided; via negativa is the best counsel, even if most avoidance is a result of poverty at the moment. There is still the option of ‘doing no harm’, but only if the contribution of unsafe healthcare to HIV epidemics so far is thoroughly investigated. If that’s not done, people would be better off to stay away from healthcare facilities.

Via Negativa: the way to low HIV prevalence?


Wajir is a city and county in Kenya’s former North Eastern Province. From a HIV perspective, the county stands out for having the lowest prevalence of all Kenya’s 47 counties, currently estimated at 0.4%. The next highest counties are Mandera (0.8%) and Garissa (0.9%). Wajir, Mandera and Garissa make up what was the province, formerly a part of Jubaland, in Southern Somalia.

Homa Bay is a town and county in the south west, formerly part of Nyanza Province, and the number one county for HIV prevalence, 26%. Indeed, the only counties with prevalence above 10% are Siaya (24.8%), Kisumu (19.9%), Migori (14.3%) and Homa Bay, which (along with Kisii and Nyamira) made up Nyanza. That accounts for one third of all HIV positive people in Kenya.

The question of why HIV prevalence is so high in certain parts of Kenya is usually answered, implicitly or explicitly, with half baked notions about ‘African’ sexual behavior, ‘African’ mores, ‘traditions’, sexual practices, ‘unsafe’ sex, promiscuity. In a word: sex. It’s all about sex, and in the worst hit counties experts have persuaded the US to part with hundreds of millions of dollars for mass male circumcision programs.

A lot less seems to be written about the extremely low HIV prevalence found in the north east. Look up Mandera, Garissa or Wajir on PubMed and you will only come across just over 300 papers altogether, compared to thousands for other locations (and almost 50,000 for Kenya as a whole). But it would be interesting to know how HIV prevalence has remained as low as in many western countries in the north west of Kenya, yet it has risen as high as the worst hit countries in southern Africa in the south west of Kenya.

Sex happens in north eastern counties too. In fact, condom use is generally lower in these counties. Polygamy is more common, as are intergenerational sex and marriage, phenomena the HIV industry sometimes insists are risks for HIV transmission. Knowledge about HIV transmission and how to avoid it tends to be lower in these counties, too. Birth rates are higher than in other parts of the country.

Circumcision is said to be widespread in a number of counties, not just in Wajir (and Mandera and Garissa) but also, for example, in Kilifi. But HIV prevalence in Kilifi is a lot higher, at 4.5%. The populations are predominantly Muslim in both counties, so circumcision is not likely to be the full explanation, nor is religion. There are commercial sex workers and men who have sex with men in every county, with no evidence that these practices are less common in low prevalence counties.

The north eastern counties are, in fact, very different from the rest of Kenya. Kenya was divided up on ethnic lines by the British, which is why the territory once called the ‘Northern Frontier District’ became one province: it was, and still is, populated by ethnic Somalis. They are geographically isolated, in the sense that there are few major roads. Much of the north of Kenya is arid and sparsely populated. Even the Somalis who live elsewhere in Kenya, such as in Nairobi, tend to live in predominantly Somali suburbs.

A similar kind of isolation, albeit on a much larger scale, can be found in northern Africa. The Sahara is sparsely populated and there are few major roads traversing it. HIV prevalence is low in all North African countries. In fact, HIV arrived relatively late in North Africa, and analysis of the common subtypes there suggest that the epidemic spread to a large extent from southern Europe, and to a lesser extent from West and central Africa.

The most common HIV subtype in Kenya is type A, followed by D, with a small proportion of type C. But the most common subtype in the north east of Kenya is type C, this being the most common subtype in southern Africa, Ethiopia and a number of other countries. So the former province really does seem to have a different epidemic or ‘subepidemic’. Type C is known to have evolved later than A and D, so the former North Eastern Province’s subepidemic is newer, like those in North African countries.

But it is still unclear how the above features of certain epidemics and subepidemics are associated with very low prevalence. Instead of looking for phenomena behind very high prevalence in some south western counties, are there certain phenomena that are absent in the north west (and in North Africa)? Isolation doesn’t mean less sex, nor even less ‘unsafe’ sex, and sexual behavior is very poorly correlated with HIV transmission.

We don’t know much about Wajir, Mandera and Garissa because not much research has been carried out there, and it’s not surprising that little HIV research has been carried out where there’s little HIV transmission. But what about other healthcare research? I notice almost all the articles on PubMed are about HIV, and were published in the last 20-30 years. So the area has been isolated from research for a long time.

Now, if there are few roads and limited infrastructures, is healthcare infrastructure similarly limited? It could be expected that access to healthcare facilities is poor and that many people rarely or never go to a hospital, or see any kind of health professional. The majority of women probably give birth at home, coverage of mass drug administration programs, including routine immunizations, is probably lower for these and other more isolated counties.

Borrowing Nicholas Nassim Taleb’s ‘via negativa’ in his book ‘Antifragile’, perhaps HIV prevalence in the north east of Kenya (and in North Africa) has remained low because of infrequent contact with healthcare facilities. This is not to say that healthcare facilities are unsafe in the north east, although it does suggest that they are unsafe in high prevalence counties. Also, it is suggested that HIV is circulating in health facilities, more in some than in others.

Many (including Taleb) like to repeat that ‘absence of evidence is not evidence of absence’. There is a possibility that HIV has been, and is still circulating in health facilities in Kenya, and may account for a significant proportion of infections, perhaps the majority of infections. Little research has been carried out to estimate the relative contribution of healthcare associated HIV transmission. We will never know until the evidence is sought: does limited contact with healthcare keep HIV prevalence low in the north east of Kenya?

HIV: A Rich Seam in a Long Abandoned Mine?


Here’s a stomach-churning quote from The Eugenics Review, 1932: “East Africa [has] a heavily syphilized native population”, where tests suggest that “not less than 60 per cent. to 70 per cent. of the general native population” have some kind of sexually transmitted disease.

At that time, several conditions were mistaken for syphilis (or other STIs). For example, yaws and endemic syphilis, neither of which are sexually transmitted. Prejudices about ‘African’ sexual behavior were used to prop up beliefs about prevalence of STIs (and prejudices about STIs proped up beliefs about sexual behavior).

You might think that things would have moved on a bit, what with eugenics no longer having the cache it had in the thirties, right? But the received view of HIV in high prevalence countries is that 80-90% of transmission is a result of sexual behavior, mostly heterosexual behavior.

From this ‘expert’ opinion about ‘Africa’, it is assumed that high HIV prevalence indicates high rates of ‘unsafe’ sexual behavior, and that high rates of ‘unsafe’ sexual behavior (or rates that are assumed to be high) indicates high HIV prevalence, or that prevalence will reach high levels in the foreseeable. It’s pretty easy to spot the pig-headed circularity in the argument.

So, how far have we moved on 80 years after the Eugenics Review quote, above? Here’s Catherine Hankins, from the Amsterdam Institute for Global Health and Development (formerly a senior officer in UNAIDS):

As Hankins surmises, in some cultures what you do with your sexual partners over time is different. In the West we tend to be serially monogamous.

In Africa, if you’ve had sex with someone at some point, the door isn’t considered closed on picking up on that relationship again.

“Take a middle-class African businessman. He has had five women – nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a ‘deuxième bureau’ – a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.

“Within a year he may have infected four other women. Now, if I’ve had five sexual partners and catch HIV from the fifth, as a western woman I’m unlikely to return to the other four and infect them!”

You might object that it is unfair to criticize what is clearly just an opinion, however ‘expert’. But policy is based on such opinions, HIV programs are guided by them, enormous amounts of money are spent (entirely in vain) on them. Worse still, the scientific data so assiduously collected shows that Hankins is as wrong as the eugenicists. Ostensibly, at least, Hankins was responding to scientific findings, published in a scientific journal, not to someone’s opinion.

You can look through any Demographic and Health Survey you like, where you will find numerous tables about sexual behavior, family life, people’s ability to recall selective tidbits about HIV, etc, but you will not find a country where a large number of people have lots of sexual partners, or engage in sexual activities considered to be unsafe.

In addition, the circularity mentioned above comes across very clearly in Hankins’ invective: HIV prevalence is high because rates of ‘unsafe’ sexual behavior are high, and we know about sexual behavior because HIV prevalence is high. Hankins clearly believes all these prejudices that she expresses about sexual behavior among ‘Africans’!

Three countries account for about one third of all HIV positive people, globally; South Africa (6.8m), Nigeria (3.2m) and India (2m). The same three countries also accounted for more than half of all aids-related deaths in the past few years. It is notable that prevalence is low in India, at less than 0.3%. This compares to about 3% prevalence in Nigeria, and about 19% in South Africa, more than 60 times higher than in India (and it can rise to well over 100 times higher in certain demographics).

Whatever is behind the huge rates of HIV transmission in these countries, which tend to be concentrated in certain geographical areas and populations, it is likely to be something that is amenable to scrutiny, whether it involves the copious quantities of sex that UNAIDS would claim, or something else, for example, dangerously low standards of hygiene and infection control in some health facilities.

Hankins seems intent on mimicking the media approach to HIV, concentrating on relatively rare and infrequent phenomena (deliberate transmission, ‘virgin cures’, fake healers, ‘traditional’ practices, etc), but failing to notice the appalling conditions in healthcare in some of the areas worst hit by HIV. What is it that is deflecting attention from everyday phenomena, allowing such extreme views to prevail, but failing to reduce infections in the worst hit areas?

Hepatitis C eradication and profit


Note: This is a guest blog by Helmut Jäger. Dr Jäger’s website and blog provides more information and thoughtful comments on healthcare issues at: http://www.medizinisches-coaching.net/

Good news: hepatitis C can be cured

Since 2016, the World Health Organization recommends treating hepatitis C infection with sofosbuvir (NS5B-Polymerase-inhibitor)The manufacturer (Gilead) demands an extremely high price, and

“.. the public paid twice: for the pharmaceutical research and for the purchase of the product. The enormous profits flow to the Gilead shareholders.”(Roy BMJ 2016, 354: i3718)

The evidence for the effectiveness of direct-acting antivirals (DAA) for chronic hepatitis C comes from short-term trials. Cochrane is unable to determine the effect of long-term treatment with these drugs:

DAAs may reduce the number of people with detectable virus in their blood, but we do not have sufficient evidence from randomised trials that enables us to understand how SVR (sustained virological response: eradication of hepatitis C virus from the blood) affects long-term clinical outcomes. SVR is still an outcome that needs proper validation in randomised clinical trials. (Cochrane 18.09.2017: http://www.cochrane.org/CD012143/LIVER_direct-acting-antivirals-chronic-hepatitis-c.)

Egypt is particularly affected by hepatitis C. Here the government negotiated special discounts with Gilead, so that relatively cheap treatment will be available. It’s the foundation of just another lucrative business based on a man-made disaster.

tourcure

Tour’n Cure: The profitable medical eradication of a problem that would not exist without medicine.

Bad news: Hepatitis C will still be transmitted by skin piercing procedures

About 2-3% of the world’s population is infected with the hepatitis C virus (HCV); 350,000 of these 130-170 million people die per year. HCV causes liver infections, which are chronic in more than 70% of infected persons. That is, they do not completely cure after an infection. After one or maybe two decades, the damaged liver can fail, or develop cancer. The survival rates are low in the late stages of the disease, even under optimal treatment conditions.

Hepatitis C viruses are very sensitive to environmental influences so they are transmitted almost exclusively through blood or blood products or unclean syringes. Unlike hepatitis B or HIV/AIDS, HCV infections through sexual contacts are rare. Hence, the incidence of HCV is an indicator of a dangerous handling of needles, syringes, other medical instruments or products that lead to a direct blood contact. And new cases of HCV are acquired most likely in health care facilities or by intravenous drug use.

Treatment of disease and prevention of new infections 

The World Health Organization (WHO) announced in 2016 that it wants to “combat” hepatitis C and “exterminate” it by 2030. (WHO 2017: http://www.who.int/mediacentre/factsheets/fs164/en/)

unsafe-needles

Hazardous needles somewhere in Africa (image: Jäger, Kinsahsa 1988)

WHO’s optimism is caused by the availability of sofosbuvir. The drug is said to have cured up to 90% of affected patients in clinical trials, and consequently was added to the WHO list of essential medicines. The pharmaceutical company Gilead faces a huge global market with high profit margins (WIPO 2015): The treatment costs in the US are US$84,000 and in the Netherlands €46,000. The production cost of the drug is estimated not to exceed US$140.(‘T Hoen 2016)

Most people affected by hepatitis C are poor. They now learn through the media that their suffering could be cured, and at the same time that this solution seems to be unavailable to them. Consequently, they will demand the necessary funds for humanitarian reasons from their governments. Gilead expects sofosbuvir will not be manufactured and sold without a license (about 100 times cheaper). The Indian authorities already concluded in 2016 a license agreement with Gilead, which will guarantee high profit rates on the subcontinent.(‘T Hoen 2016)

Attractive medical products and markets increase the risk of the production of counterfeit medicines

In India, the requirement to allow the production of the hepatitis C drug in the “national interest” license-free is not only risky for legal reasons. India already is the world’s leading producer of fake medicines. Counterfeit drugs look exactly like real ones, but contain nothing (in the best case) or poison. About 35% of the malaria drugs in the African market are fake or useless, and they are mostly from India or China (see below: fake drugs). In the case of Egypt, medical institutions tried to open up a lucrative international market (“Tour’n cure”). Therefore, it will not be long until the first fake “sofosbuvir preparations” are offered.

The history of the hepatitis C epidemic in Egypt

The disaster of hepatitis C contamination started in Egypt more than sixty years ago. Efforts to regulate the Nile increased the risk of schistosomiasis infections. These parasites cause numerous health problems, mostly in the pelvic organs, and in rare cases, cancer. The worm larvae swim in stagnant water that has been contaminated by human urine or feces, and they enter the blood system of healthy people by piercing the skin.

The frequency of these worm infections increased rapidly after 1964, when the fast-flowing Nile was tamed by the Aswan Dam. In a relatively short time 10% of the Egyptian population was colonized by the parasite. The Ministry of Health then treated large parts of the population with injections containing antimony potassium tartrate. Until 1980 this toxic compound was considered the only effective remedy for this worm-infection. Today it is no longer used, not even in veterinary medicine.

Many years after the start of the campaign an initially unexplained epidemic of hepatitis C  was noticed in Egypt. It turned out that most of the patients with hepatitis C virus received anti-schistosomiasis injections.

Those initially infected with hepatitis C virus had higher risks to be treated in health care facilities, where the virus was then transmitted to other patients. Today (according to different estimates) 3-10% of the Egyptian population is infected with hepatitis C, and 40,000 patients die per year with the disease. Because many patients are infected, today the risk to acquire hepatitis C infection in Egyptian health facilities, even in optimal hygenic conditions, is significantly higher than in countries where hepatitis C is relatively rare.(Strickland 2006, WHO 2014)

Hepatitis C epidemic in industrialized countries

But Egypt is not an isolated case. Hepatitis C affects mostly the residents of developing and emerging countries. But even in Germany more than half a million HCV infections are recorded.

In England, in 2015 the government had to apologize for the infection of nearly 3,000 people who received infected blood products between 1970 and 1990.(Wise 2015)

In the US hepatitis C is called a “hidden epidemic” because 300,000 people were infected each year a few decades ago.(Ward 2013, Warner 2015, CDC 2015, RKI 2015, Pozzetto 2014)

Syringes and blood products are dangerous if handled improperly or if they are used although they are not necessary

blood

Blood Bank in Kinshasa (Congo, 1990, image: Jäger)

Needles (in particular the worldwide introduction of disposable syringes and their inflationary use) contributed to the spread of viruses like HCV, HIV and others.(Jäger 1990-92) The problem of the HCV epidemic is caused by the health care system and its waste products that fall into the wrong hands. The causes of the infections mostly are: bad medicine or intravenous drug addiction. What happened in Egypt is just another example that sometimes (medical) solutions of seemingly controllable health problems can lead to much larger problems: because sometimes “the things bite back.”(Tenner 1997, Dörner 2003)

Therefore WHO’s strategy to eradicate hepatitis C, based only on treatments, cannot succeed as long as the much of the medical sectors in many poor countries remain dangerous-purely-commercial and in large parts uncontrolled. The WHO campaign certainly will enrich Gilead and some health institutions, but a reduction of the hepatitis C incidence will not take place if “bad medicine” and “drug addiction” are not targeted, preferably eradicated, or at least reduced.

Unnecessary medicine is risky and should be avoided

WHO and other international health organizations should strive to avoid unnecessary therapeutic skin piercing procedures, injections, surgery and transfusions, and (if these sometimes life saving procedures are necessary) establish strict quality control. The commerce of medical tourism and beauty-interventions (botox, piercing, tattoo) should be strictly controlled.

unsafe-injection

Hazardous needles anywhere else in Africa (image: Jäger)

And we should invest in training patients: They should be supported to reduce their demand for health-care-products and to increase their knowledge in order to distinguish “good” and “bad” medicine.

 More

Literature

Bad Medicine in economically weak countries (such as “fake drugs”):

Why things bite back

Take a look at: Seeking the positives, by John Potterat


In an important contribution to the history of medical research, John Potterat’s new book, Seeking the Positives, recounts his involvement in research on sexually transmitted disease and HIV. Chapter 7 recounts researchers’ failure to explain how so many Africans get HIV (chapter 7 is available for download at http://home.earthlink.net/~jjpotterat/book.html).

The AIDS epidemic has been a disaster for tens of millions of Africans. What has not been widely recognized is the damage to medical research – epidemiologists have not done what is required to show how so many Africans get HIV. In a closed-door meeting at WHO in 2003, John described HIV epidemiological research in Africa as: “First World researchers doing second class science in Third World countries.”

How will the medical research community rebuild competence after its deliberate incompetence in not explaining and thereby containing Africa’s AIDS epidemic?

John’s book offers much more than a history of HIV research failures. He and his staff at the Colorado Springs public health department reduced STD in the community. Working with researchers from CDC and elsewhere, they tested new control strategies and documented what works – demonstrating the importance of contact tracing and network analyses to understand and limit STD transmission. Research in Colorado Springs has had an impact on STD prevention programs around the world.

But this is not only history – the human costs of research failures are continuing. According to the latest UNAIDS’ estimate, 1.4 million Africans got HIV in 2014 (see:http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdf). If someone could tell Africans how they are getting HIV, they might be able to protect themselves and collectively to wind down their epidemic.

I recommend the book for reading in epidemiology classes – to foster truthniks and doubters, so we will have the experts we need in future health crises. When you get the book, I recommend you start with a brief look at Appendix 3, which lists individual and STD/HIV program awards.

Charging HIV-positive husbands and wives with adultry — and lying about it


return to first research page

A wife, husband, and children can be hurt when a gossip — with no evidence — spreads rumors that the wife or husband have lovers.

This situation threatens many HIV-positive married men and women in Africa. HIV prevention programs say most infected adults — including wives and husbands with HIV-negative partners — got HIV from lovers, even if there is no evidence they had lovers, and even if they deny it. Such HIV prevention messages are equivalent to rumors — averring without evidence that people had secret lovers and lied about it.

Researchers have supported such unfounded “rumors.” For example, a UNAIDS-funded study in Zimbabwe followed adults to see who got HIV and what were their risks. After finding and reporting that “[t]hirteen of 67 individuals seroconverting in this study reported no sexual  partners in the inter-survey period..” the authors opined: …misreporting of sexual behaviour may explain some of these infections….”[1]

Wife with HIV, husband without

Many women are victimized by such unsupported suspicions. National surveys in 24 African countries during 2010-14 report the percentages of couples with HIV in one or both partners. In 14 of 24 countries, if a married woman was HIV-positive, more than 50% of husbands were HIV-negative (Table 1). This is not explained by women getting HIV before marriage – even among married women aged 30-39 years, an HIV-positive wife was more likely to have an HIV-negative than an HIV-positive husband in 12 of 24 countries (Table 1).

Table 1: Among married women who are HIV-positive, what % of  husbands are HIV-negative?

wife+ husband-

Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence).

Seeing such data and recognizing “women’s low self-reported levels of extramarital sex, a World Bank economist opines: “…I conclude that the sizable fraction of discordant female couples is extremely difficult to explain without extramarital sex among married women.”[2]

Most countries in Africa routinely test pregnant women for HIV. Hence, the wife is often the first partner to know her status. If the husband subsequently goes for a test, he is more likely to test HIV-negative than HIV-positive in most countries across Africa.

What is he to think? Should he believe his wife? Or should he believe healthcare professionals (behaving like gossips) who propose his wife lied? It is relevant, as well, that healthcare professionals have a conflict of interest – the alternative to blaming wives for adultery is to acknowledge their HIV may have come from unsafe healthcare.

Husband with HIV, wife without

Similarly, blaming all HIV on sex encourages wives to blame HIV-positive husbands for having lovers and lying about it. In 15 of 24 countries, when the husband is HIV-positive, at least 50% of wives are HIV-negative (see Table 2).

Table 2: Among married HIV-positive men, the % of wives HIV-negative

husband+ wife-
Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence).

References

1. Lopman, Garnett, Mason, Gregson. Individual level injection history: A lack of association with HIV incidence in rural Zimbabwe. PLoS 2008: Med 2(2): e37. Available at: http://www.plosmedicine.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pmed.0020037&representation=PDF

2. de Walque D. Sero-discordant couples in five African countries: implications for HIV prevention strategies. Pop Dev Review 2007; 33: 501-523. Abstract available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1728-4457.2007.00182.x (accessed 28 October 2018).

Cambodia


Roka Commune outbreak

In November 2014, a 74-year old man in Roka Commune, Cambodia, tested HIV-positive. He sent his granddaughter and son-in-law for tests. They also tested positive. Alarmed by these unexpected HIV infections, more residents of Roka Commune went for tests; many were HIV-positive.

The next month, December 2014, Cambodia’s Ministry of Health initiated an investigation with collaboration from WHO, the US CDC, UNAIDS, UNICEF, and the Pasteur Institute in Cambodia.[1]

Three papers report results from this investigation.[2,3,4] Results are limited to 242 persons testing HIV-positive through end-February  2015. Comparing HIV-positive residents with neighbors, infected residents had received more injections, infusions, and blood tests. Reports say nothing about specific failures in infection control (e.g., did providers give injections after changing needles but reusing syringes? did providers give infusions with reused plastic tubes and saline bags?). Many persons were co-infected with hepatitis C, which unsafe healthcare had been spreading in the community for years before the HIV outbreak.

Foreign organizations helping with the investigation sequenced several hundred HIV (determined the order of their constituent molecules) from the community. Almost all sequences were very similar, showing fast transmission from 1 to 198 infections in a few short years. These sequences can be presented as branches in a “tree” (see below, Figure 1). The upper right section of the tree shows the cluster of very similar sequences from Roka. (Most sequences in the lower part of the tree are “controls,” which means the HIV came from other times and places.) The tree shows each HIV infection as the right end-point of a short horizontal line. The left ends of these lines show estimated connections to earlier estimated infections. The timeline at the bottom of the figure shows time going from left to right, showing the estimated dates of transmission from earlier to later infections.

Figure 1: Cluster of 198 infections in Roka, Cambodia, linked by transmissions during 2011-14[5]

env_timetree_baltic (1)

Using information from these reports, one of the managers of this website (DG) estimated the transmission efficiency of HIV through contaminated injection equipment at 4.6%-9.2% (this is the risk that an injection administered to an HIV-positive person during the outbreak transmitted HIV to a subsequent patient).[6]

Other information related to the Roka outbreak

In early 2017, a newspaper article reported 292 infections in the outbreak.[7]

As in many other nosocomial HIV outbreaks, children were on the front lines: 22% of cases were in children <14 years old.[2]

Alerted by the investigation, people looked for unexpected infections and unsafe practices elsewhere in Cambodia. A December 2015 BBC article – one year after Roka broke into public view – reports continued and common unsafe practices.[8] In mid-February 2016, an NGO reported 14 patients testing HIV-positive – 10 from Peam village in Kandal Province, a village of 1,000, and 4 from neighboring villages[9]. The article reported 32 previously known infections in Peam village, for a total of 42 or 4.2% of 1,000 villagers. In interviews, persons newly identified with HIV denied sexual risks and suspected infection from injections by a specified local doctor.

See also these dontgetstuck.org blogs posts

References

1. Eng Sarath. Ministry of Health, Cambodia. 24 December 2014. HIV cases in Sangke district, Battambang. Available at: http://www.cdcmoh.gov.kh/97-hiv-cases-in-sangke-district-battambang

2. Mean Chhi Vun et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. Morbidity and Mortality Weekly Report 2016: 65:  142-145. Available at: http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm (accessed 28 March 2016).

3. Saphonn V, Fujita M, Samreth S, et al. Cluster of HIV infections associated with unsafe injection practices in a rural village in Cambodia. J Acquir Immune Defic Syndr 2017; 75: 285-e86. Available at: https://journals.lww.com/jaids/Citation/2017/07010/Cluster_of_HIV_Infections_Associated_With_Unsafe.19.aspx (accessed 12 February 2018).

4. Rouet F, Nouhin J, Zheng D-P, et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin Infect Dis 2017; epub ahead of print. Available at: https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1071/4689456?redirectedFrom=PDF (accessed 12 February 2018).

5. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/ (accessed 15 November 2018). This figure has been copied by permission from Bedford Lab.

6. Gisselquist D. HIV transmission efficiency through contaminated injections in Roka, Cambodia. biorxiv 2017. Available at: https://www.biorxiv.org/content/biorxiv/early/2017/05/15/136135.full.pdf (accessed 12 February 2018).

7. Millar P. How the residents of Cambodia’s “HIV village” are coping more than two years on. Southeast Asia Globe, 15 March 2017. Available at: http://sea-globe.com/how-the-residents-of-cambodias-hiv-village-are-coping-more-than-two-years-on/ (accessed 14 August 2017.

8. John Murphy. BBC, 17 December 2015. A country in love with injections and drips.
Available at: http://www.bbc.com/news/magazine-35111566

9. Aun Pheap, George Wright. Doctor denies spreading HIV in latest outbreak. Cambodia Daily News 22 February 2016. Available at: https://www.cambodiadaily.com/news/doctor-denies-spreading-hiv-in-latest-outbreak-108791/ (accessed 28 March 2016).

See also:

Kehumile Mazibuko. News Tonight Africa, 4 December 2015. Cambodia: unlicensed medical practitioner sentenced for infecting more than 100 people with HIV. Available at: http://newstonight.co.za/content/cambodia-unlicensed-medical-practitioner-sentenced-infecting-more-100-people-hiv

Khy Sovuthy, Anthony Jensen. Cambodia Daily, 8 December 2015. In HIV case, key evidence trails behind guilty verdict. Available at: https://www.cambodiadaily.com/news/in-hiv-case-key-evidence-trails-behind-guilty-verdict-102320/

Why do UNICEF, WHO, and UNAIDS choose to stigmatize rather than protect African youth?


(return to first research page)

Beginning in early 2015, UNICEF with UNAIDS, WHO, and other organizations initiated the All In to #EndAdolescentAIDS program. The program has some good points – e.g, promoting more HIV testing and better treatment for HIV-positive adolescents.

However, the program is off the mark on prevention. It says nothing about risks adolescents in Africa face to get HIV from blood-contaminated instruments during health care (blood tests, dental care, injections, etc) and cosmetic services (tattooing, manicures, hair styling).

Ignoring such risks while focusing only on sex stigmatizes those who are already infected (aha! you had careless sex!) and misleads those who are HIV-negative to ignore blood-borne risks.

Evidence HIV-positive adolescents did NOT get HIV from sex

The best available evidence – from national surveys – suggests less than half of HIV infections in African adolescents came from sex. For example, in national surveys in Kenya, Lesotho, and Tanzania, majorities of HIV-positive youth aged 15-19 years reported being virgins (Table 1). Across these three countries, 57% (36 of 63) HIV-positive youth in the survey samples reported being virgins.[1]

table 1 adolescents

Some HIV-positive teens may have gotten HIV from their mothers when they were babies; but without antiretroviral treatment (ART), which arrived late in Africa, survival to adolescence would be unusual. Thus most adolescent virgins with HIV likely got it from blood contacts. If virgins are getting HIV that way, some non-virgins are likely getting it the same way.

Using data from national surveys in Lesotho, Swaziland, and Zimbabwe, and assuming no lying about sexual behavior, Deuchert estimates only 30% of HIV-positive never-married adolescent women aged 15-19 years got infected through sex.[2] What if some lied? Deuchart does the math: “The assumption that HIV is predominantly sexually transmitted is valid only if more than 55% of unmarried adolescent women who are sexually active have misreported sexual activity status.” (Tennekoon makes a similar analysis.[3])

But let’s cast the net wider: During 2003-15, 45 national surveys in Africa reported the %s of (self-reported) virgin and non-virgin youth aged 15-24 years with HIV (see Table 2 at the end of this blog post). Young men and women got HIV whether or not they virgins.

For example, in Congo (Brazzaville), Rwanda, Guinea (2012), Democratic Republic of the Congo, and Gambia, the %s of young women that were HIV-positive was greater among virgins than among all young women. Among young men, the % with HIV was the same or greater among virgins vs. all young men in Tanzania (2007-08), Congo (Brazzaville), Sierra Leone (2013), Guinea (2005), Mali, Sao Tome and Principe, Burundi, Benin, Burkina Faso, Niger, and Gambia.

Across all 45 surveys, the median ratio of the %s of self-reported virgin young men with HIV to all young men with HIV was 0.75 (last line, Table 2). Across all 45 surveys, the median ratio of the %s of self-reported virgin young women with HIV to all young women with HIV was 0.33 (last line, Table 2). And, as noted above, many infections in non-virgins likely came from blood-borne risks.

The only way to say most HIV infections in adolescents in Africa come from sex is to throw away the best evidence we have – to assume survey data are wrong because self-reported HIV-positive virgins are lying. That seems to be what experts at UNICEF, WHO, and UNAIDS have done – ignoring evidence to accuse HIV-positive adolescents of unwise sex, and accusing them also of lying if they say they are virgins.

Stigmatizing HIV-positive African youth for unwise sexual behavior is a form of abuse. Because young women are more likely than young men to be exposed to HIV during more frequent health care and cosmetic procedures, not warning about bloodborne risks contributes to unrecognized violence and abuse targeting African women.

table 2d adolescentstable 2e adolescents

References

1. Brewer DD, Potterat JJ, Muth SQ, Brody S. Converging evidence suggests nonsexual HIV transmission among adolescents in sub-Saharan Africa. J Adolescent Health 2007; 40: 290-293. Partial draft available at: https://www.deepdyve.com/lp/elsevier/converging-evidence-suggests-nonsexual-hiv-transmission-among-105k5VXKQE (accessed 19 December 2015).

2. Deuchert E. The Virgin HIV Puzzle: Can Misreporting Account for the High Proportion of HIV Cases in Self-reported Virgins? Journal of African Economics, October 2011, pp 60-89. Abstract available at: http://jae.oxfordjournals.org/content/20/1/60.abstract (accessed 19 December 2015).

3. Tennekoon VSBW. Topics in health economics. PhD dissertation. Washington State U, 2012. Available at: http://research.wsulibs.wsu.edu:8080/xmlui/bitstream/handle/2376/4270/Tennekoon_wsu_0251E_10484.pdf?sequence=1 (accessed 18 December 2015). See also an earlier paper by

 

 

 

 

 

Africans Several Steps Ahead of ‘Global’ Health?


Many articles about ebola continue to mention a two year old boy who was probably infected with the virus some time in December of 2013. The articles refer to the boy as the ‘index case’, as if his being infected set off the recent epidemic in West Africa.

In fact, working back from confirmed cases, the trail goes cold before December 2013. There is no data about the virus and the investigation becomes pure speculation at this point. There is no evidence that the boy was infected by a bat, nor is there evidence that bats or other animals in the area carry ebola.

Articles mentioning this two year old boy, bats, ‘corpse touching’ at funerals and even sexually transmitted ebola (of which no cases have ever been confirmed), are commonplace. It is not just the media that revel in them, but also many scientific and medical articles.

But the people of West Africa seem oblivious to many of the warnings they have been receiving about ebola. And maybe they are right?

Apparently Liberians are completely unconvinced about the dangers of eating bush meat.

In Guinea, cases of malaria and deaths from malaria far exceed numbers of people infected with ebola and deaths from ebola. More importantly, the number of deaths from malaria has increased because people have been avoiding health facilities, fearing they might be infected with ebola.

Worse still, their condition may be mistaken for ebola and they could end up in an ebola treatment unit, with other suspected ebola cases, some of which turn out to have the virus.

To fear health facilities in Africa is perfectly logical. Healthcare conditions in most African countries are appalling. Not just ebola, but HIV, TB, hepatitis and other diseases have been spread by unsafe healthcare practices, such as reused injecting and other skin-piercing instruments.

CDC, UNAIDS, WHO and other health agencies may be convinced by their own propaganda, but people in Guinea, Sierra Leone and Liberia are not. And, it seems, they have entirely valid reasons for ignoring this ‘official’ advice. Unfortunately, that means many people will suffer from and die from easily treated conditions.

But ‘global’ health is in crisis because those most likely to suffer from ‘global’ health conditions are probably least likely to trust health facilities in their country. The interference of various international agencies (or local offices of international agencies) is only likely to increase this mistrust.

Nigeria has problems with ‘quack’ doctors. Nigerians escaped a serious ebola epidemic, but the second largest HIV positive population in the world resides in Nigeria. Nigeria has also swallowed the dubious claims of UNAIDS and others that HIV is almost always transmitted through heterosexual sex in Africa countries.

As a result, the country has passed punitive laws about ‘non-disclosure’, exposure and transmission, but only, it appears, when transmission is sexual.

The ebola epidemic has shown that people find it hard to trust ‘global’ health agencies. Warnings about various sexual practices and HIV have also fallen on deaf ears. But perhaps ordinary people are right to ignore ‘global’ health agencies. Perhaps bush meat and ‘corpse touching’ are either not as common or not as risky as we have been told. And perhaps the appalling conditions to be found in health facilities are much more risky than we have been told.

South Africa – Never Mind HIV, We’ve Got Penis Transplants


One ebola case, out of tens of thousands identified over nearly forty years, may have been sexually transmitted; the evidence is slim, but CDC and others really want this one case to be used to stress that people should be made aware of this highly remote possibility (if it is even remotely possible).

Strong evidence that a significant proportion of transmissions of ebola is a result of unsafe healthcare is quietly ignored; CDC and others don’t wish to warn people that the healthcare systems expected to deal with such outbreaks are far too weak to keep people alive, and are likely to be part of the problem in the cases of ebola and HIV.

South Africa has transplanted one penis on to a man who lost his through a botched circumcision. The US government is ploughing a few billion dollars into circumcising tens of millions of African adults (and an unknown number of children), so they will not be in a hurry to warn people about the hundreds of botched circumcisions reported every year (nor the uncounted thousands that remain unreported).

The English Guardian has a lengthy article about this single penis transplant, and has had a few, equally salacious articles, about botched circumcisions that occur in traditional, non-sterile settings. That same smug, self-satisfied newspaper has had next to nothing to say about appalling conditions in healthcare facilities in places where HIV prevalence is very high, or about the possible role of unsafe healthcare in transmitting HIV, hepatitis C and B, ebola, TB and various other diseases.

The craze for circumcising African men is based on the view that HIV is almost always ‘spread’ by men, through ‘unsafe’ sex, which almost every ‘African’ engages in, almost all the time (a view based entirely on prejudice). The press is completely unmoved by the fact that circumcision of men may increase HIV transmission from males to females, considerably.

The media goes crazy about the ‘possibly sexually transmitted’ ebola case, even exaggerating it into a dead certainty that it was sexually transmitted; and they are happy to promote the view that Africans engage in types and levels of sexual behavior that should be curbed by various (failed) measures, paid for by donor money. But this is just a continuation of what various colonizers began.

The racism behind the view that HIV is almost always transmitted through heterosexual contact in (some) African countries, but no non-African countries, has always remained unremarked by the press. The prejudice behind singling out uncircumcised African men and HIV positive women for intense vilification is rarely mentioned.

The fact that about 7% of HIV positive women in South Africa, the country with the largest HIV positive population in the world, report being sterilized forcibly, receives occasional mention. But readers seem to prefer articles about penis transplants and one possibly sexually transmitted case of ebola, it appears.

The Daily Maverick has an article about what the author dubs the ‘new denialism’; the health services in South Africa are failing, they are even failing HIV positive people, despite the huge amounts of money that the country is said to have received.

The health services are unable to cope with any illnesses and throwing money at HIV will not result in reasonable numbers of well trained and equipped staff, adequate supplies and, most of all, levels of cleanliness and hygiene that eliminate the possibility that many patients will end up being infected with something in hospital that is far worse than what they were admitted with.

There is nothing new about this denialism, but it needs to be recharacterized; health services are not just inadequate, they are dangerous. Aidsmap.com are certainly not alone in bemoaning the fact that many women in South Africa are infected with HIV relatively late in their pregnancy, sometimes after giving birth, even many months after.

Nor are Aidsmap alone in failing to consider the possibility that some of those women, perhaps most of those women, were infected with HIV through unsafe healthcare, reused syringes, needles, various types of equipment and various processes that require a far better level of hygiene than will be found in extremely high prevalence provinces, such as KwaZulu Natal and Mpumalanga.

The pharmaceutical industry does very well out of HIV and several other diseases that have hit the headlines in the mainstream press, and are deemed worthy of enormous funding. Many NGOs have been built by HIV money and will only thrive and prosper as long as a few diseases are considered worthy of massive funding.

The press loves a story about a penis transplant in a country too poor to prevent thousands of unnecessary deaths every year, of women giving birth, babies, children and adults with easily treated and prevented diseases. Appalling conditions in health services in most African countries does not merit the attention of the press, they are far too commonplace. If a story from ‘Africa’ has even the remotest connection with sex, publish it; if not, forget it.