Bloodborne HIV: Don't Get Stuck!

Part VI explored the possibility that family planning and Sexually Transmitted Infection (STI) services may have been provided in health facilities that would later be deemed unsafe in the context of HIV, involving reuse of syringes and other equipment with inadequate or no sterilization. Many determinants have been identified for STIs throughout the twentieth century, all over the world. They include poverty, poor education, unemployment, ‘promiscuity’ (Meheus, 1974), low prevalence of contraception and others. STI prevalence tended to be higher among men than women, high in both urban and rural areas, higher among unmarried than married people (Hopcraft, 1973) and fairly evenly distributed around a country such as Kenya. In contrast, HIV is more likely to be associated with relative wealth, better education, employment, proximity to roads and other infrastructure, higher use of contraception, urban dwelling, marriage and others. More women than men are infected, associations with sexual behavior considered unsafe are often not very strong and prevalence is unevenly distributed, with a few hotspots in Kenya and many ‘coldspots’. One might logically conclude that, while HIV can be transmitted sexually, it is often transmitted in other ways, and that is why patterns of infection for HIV differ so much from patterns of infection for other STIs.

However, there are important overlaps in these patterns of STI and HIV infection. For example, HIV prevalence was found to have reached 4% among Nairobi sex workers in 1981 and increased to 61% by 1985; this was established by retrospectively testing stored blood samples (Piot P, 1987). Females infected with non-HIV STIs in the past were generally found to be engaged in sex work or had a partner who had visited a sex worker. Prevalence of STIs was often high in certain occupational groups, such as transport workers, soldiers and those employed in extractive industries. As a result, these and other groups had long been targeted by STI eradication programs; sex workers had also been targeted by various family planning initiatives. This suggests that those facing high risks for infection with STIs, or assumed to face high risks, may have had increased non-sexual risk of being infected with HIV once that virus began to spread (having established itself several decades before). Although HIV prevalence went up to 81% among sex workers in Nairobi, it peaked in 1986 and declined steadily for nearly 20 years without any reasonable explanation being found for this trajectory (Kimani J, 2008). Oddly enough, neither Piot et al nor Kimani et al consider the very strong possibility that sex workers (and members of other targeted groups) were systematically infected with HIV through unsafe healthcare until this risk was eventually recognized (or perhaps changes in practices reduced the risk of transmission without anyone noticing the impact this was having on healthcare transmission until much later?).

In the early 80s, no precautions had been taken to prevent the transmission of blood-borne viruses such as HIV in health facilities, as the virus had only just been discovered. Throughout the 80s, as it became apparent that health facility transmission was (or could become) a significant risk, certain measures were taken to improve safety. But the changes would not have been adequate to eliminate transmission altogether. In the 90s, as mentioned in Part III, access to health facilities declined, which may have inadvertently protected many people from infection; HIV incidence in the general population peaked some time in the 90s, at a time when visitor numbers to health facilities would have been falling as a result of increasing poverty, the introduction of ‘user fees’, cuts in service provision and other factors. Sex workers and others thought to be ‘promiscuous’ must have faced a very high risk of being infected with HIV in STI and family planning facilities, although the risk must have decreased considerably some time in the 80s and continued to decline, without ever being completely eliminated.

As for those not considered to be so ‘promiscuous’, they would also have faced high risks in general health facilities. Family planning and STI facilities were often integrated into general healthcare services. Women attending antenatal care (ANC) services and giving birth may have faced higher risk than others (aside from sex workers and other groups targeted by STI and family planning programs). This makes it less surprising that very high HIV rates were found in ANC clinics from the late 80s onwards. HIV prevalence is often highest among women of childbearing age. While these same women may (or may not) be more sexually active that others among whom HIV prevalence is lower, they clearly face increased non-sexual risk of infection with HIV at ANC clinics that are not particularly safe. Family planning services were promoted widely, often aggressively promoted, and not just to those thought to be ‘promiscuous’. Family planning, ANC, contraception and even general health services tend to be more accessible and more utilized in urban areas, by wealthier, better educated people (Hopcraft, 1973), the very groups found to be more likely to be infected with HIV. So people with HIV are more likely to have faced various non-sexual risks, whatever about their sexual risks. Why do UNAIDS and the HIV industry seem only to consider their sexual risks? Piot et al and Kimani et al are not exceptional in completely ignoring the possibility of massive levels of healthcare transmission of HIV; the entire industry has grown out of denying that unsafe healthcare could have played a part in transmitting a virus that is a lot less efficiently transmitted through heterosexual sex.

For a long time in Kenya (and other developing countries), family planning had been seen as a means of ‘promoting economic development’, as well as ‘improving maternal and child health’. It wasn’t just highly intrusive and aggressively promoted because it was seen as beneficial to Kenyans and other Africans, but also because it was seen as a means of reducing population growth and averting an eventual global shortage of food, water and vital resources. In the same way that preventing and treating diseases in developing countries was a way of ensuring a ready supply of cheap labor in resource rich countries, family planning was seen as a way of controlling birth rates and population increases beyond what was needed for labor. For many NGOs operating in African countries now, family planning is development; and ‘maternal and child health’ consists of, pretty much, family planning. It is seen as something of a truism that maternal and child deaths can be reduced most readily by reducing fertility rather than, say, improving conditions in hospitals and elsewhere.

A 1973 paper reveals something about conditions in STI clinics in Uganda (Arya, 1973). For a start, it is pointed out that over 90% of the population lives in rural areas. Therefore, most of the population’s health needs are catered for by rural health centers, dispensaries and other minor facilities, staffed mainly by auxiliaries, rather than by more highly trained professionals. Whether it is because STIs were common or because the colonial and post-colonial administrations were exceptionally interested in them, Arya argues that “venereal disease played an important role in the organization of the medical services in Uganda in the beginning of this century.” Mulago Hospital, started in the second decade of the 20^th century as an STI clinic, became and remains the largest referral hospital in the country. This is similar to Kenya, with specialist STI services being available in Mombasa and Nairobi for many decades. Health expenditure is low, estimated at around one dollar per year per person in the mid 70s, but basic health services were provided free of charge. Arya alludes to the lack of success of most STI programs, in both developing and rich countries, in bringing these diseases under control; he suggests that there are other diseases that may be in more urgent need of attention. Arya also notes that private practitioners provide STI services, mainly in larger towns, and that the quality of these services is unknown.

Arya published a paper in 1976 about the role of medical auxiliaries in STI control in developing countries (Arya & Bennett, 1976). In common with some other authors, Arya and colleague draw attention to the high disease burden faced by developing countries, coupled with the scarce resources, human, financial and material. These are particularly acute in rural areas, where most people live, but where well qualified professionals are reluctant to work. The authors also feel that STI services are mismanaged to the extent that they may be causing more problems than they are solving, with high prevalence resulting from “inadequate treatment, improper treatment or no treatment at all”. They mention high treatment default rates, find the contribution of private practitioners to STI control ‘questionable’ and conclude that the overall quality of services is poor. Diagnoses were unreliable (Burney, 1976), patients were receiving repeated injections of small doses of penicillin, which increased resistance, etc. Another paper notes the injection of large volumes of penicillin in some countries, which is likely to have involved the use of glass syringes and reusable needles in those days (Meheus, 1974). Contact tracing was generally beyond the capacity of STI service providers. Arya and Bennett recommend that medical auxiliaries specialize in STIs and that their training includes “knowledge of the local socio-cultural factors which largely determine traditional sexual mores” and note that STI patterns “differ from those in the western nations and may even vary from one area to another within a country”.

The papers cited above and in Part VI give a few insights into what things were like in terms of STI programs in Kenya and Uganda in the 1970s. Many of those said to be dying of ‘slim disease’ in Uganda in the early 1980s could have been infected with HIV as long as ten years before. If the rate of new infections peaked in the late 1980s, transmission would have been increasing throughout the 1970s, reaching its peak in the late 1970s. Why incidence peaked and then declined is another story. It may have had something to do with the 1978-1979 war with Tanzania (wars tend to be periods of low HIV transmission (Gisselquist, 2004)), the civil war from 1981-1986 or, much more likely, a combination of factors. Incidence began to increase a few years later in Kenya, perhaps in the mid 1970s, reaching a peak in the early 1990s, as discussed elsewhere. However, incidence started to increase earlier among certain groups, such as sex workers, transport workers and others who, significantly, had been targeted by STI eradication programs for decades. Incidence also would have peaked and begun to decline earlier in these groups.

Conditions in Kenyan health facilities in the 1970s, especially those providing STI and family planning services, were poor. If a blood-borne virus were to establish itself in one or more of these facilities, there would have been plenty of scope for it to be transmitted widely, not just among populations aggressively targeted by various health programs, but also among those requiring other health services, such as antenatal care. The risks of widespread transmission of HIV in health facilities were not recognized for a number of years and many more years had passed before any of these risks were addressed (some have yet to be addressed). But western HIV awareness campaigns were hijacked long ago by various parties who wished to present the virus as one transmitted almost entirely through ‘promiscuity’, and who wished to deny the possibility of transmission in health facilities. Because most of those infected in African countries were heterosexual, a different story about transmission needed to be created. Unfortunately, the same campaigns and strategies were exported from wealthy countries, where transmission was almost entirely a result of male to male sex or intravenous drug use. These campaigns were supremely unsuccessful in Kenya, but this was blamed on the failure of individuals to change their sexual behavior, rather than on any non-sexual mode of transmission.

If HIV transmission in health facilities and through other non-sexual modes continues, the virus will not be eradicated. More poignantly, if health facility transmission had been addressed in the 1980s, when it was realized that this was a very efficient mode of transmission, the virus would never have infected so many people. Some of the worst epidemics in the world only got going in the late 1980s or early 1990s, such as Zimbabwe, Botswana, South Africa, Swaziland, Mozambique and others. Many of the biggest players (bureaucrats, politicians, publicists, academics, industrialists, etc) currently driving the HIV industry have been in the business since the 1980s. Must Kenyans and other Africans wait till these ‘experts’ are gradually replaced by more enlightened personages? It is to be hoped that new generations of practitioners are not obliged to choose between adopting the deeply engrained institutional prejudices of their profession, or accepting the status of ‘dissident’ or ‘denialist’, unable to publish, teach or even present their views to the industry.

REFERENCES:

Arya, O. (1973). Changing patterns in the organization of the venereal diseases and treponematoses service in Uganda. Brit. J. vener. Dis, 134-138.

Arya, O., & Bennett, F. (1976). Role of the medical auxiliary in the control of sexually transmitted disease in a developing country. Brit. J. vener. Dis., 116-121.

Burney, P. (1976). Some aspects of sexually transmitted disease in Swaziland. Brit. J. vener. Dis., 412-414.

Gisselquist, D. (2004). Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa. SAHARA J., 114-27.

Hopcraft, M. V. (1973). Genital infections in developing countries: experience in a family planning clinic. Bulletin of the World Health Organization, 581-586.

Kimani J, K. R.-A. (2008). Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence. AIDS, 131-7.

Meheus, A. D. (1974). Prevalence of gonorrhoea in prostitutes in a Central African town. Brit. J. vener. Dis., 50-52.

Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.

Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.

It might sound reasonable to start a history of a virus that was only identified in the 1980s in the same decade, or perhaps the decade before, just to be safe. But many of the phenomena that are said to be involved in the HIV pandemic go back a long way. There’s no need for me to start with the earliest known historical accounts, nor even with the time the virus ‘jumped species’, from chimps to humans. That history has been well described elsewhere. But I have chosen to start at around the beginning of the 20^th century for several reasons.

HIV itself can be dated to the early part of the century using genetic dating techniques, for one thing. But also, Britain had established Kenya as a protectorate in 1895. Christianity was already on the way to becoming the predominant religion (although there had been Christian Kenyans for several hundred years). Nairobi and other cities were only ‘trading posts’, but some of them eventually became heavily (and densely) populated. Several of the most important exports in Kenya today were already significant parts of the economy many decades ago. Even international social, health, educational and financial institutions that were eventually to play an important (though by no means always positive) role in Kenya’s development have been around for over half a century. Some environmental and ecological issues that only came to a head later had already begun, and much of the country’s current infrastructure was developed early on in the British occupation, to facilitate the extraction of resources, move large numbers of workers and soldiers around, etc.

I think it will become apparent why these issues are worth looking at. There is a potentially huge list of other issues that may be relevant, but I’m concentrating on the ones that I believe are in need of greater attention. Most official accounts of HIV epidemics, from the likes of the WHO, UNAIDS and others, obsess about labels, various ‘vulnerable’ groups, specific populations said to exemplify certain kinds of behavior (almost always sexual and generally presented as somehow illicit or ‘deviant’), people engaged in certain occupations and others. Examples from UNAIDS’ latest offering (The GAP Report 2013), another multi hundred page, multicolored, expensively produced document, with some well chosen photographs are: “People living with HIV, Adolescent girls and young women, Prisoners, Migrants, People who inject drugs, Sex workers, Gay men and other men who have sex with men, Transgender people, Children and pregnant women living with HIV, Displaced persons, People with disabilities [and] People aged 50 years and older”; but other groups can easily be generated, and no doubt are, as and when required.

Naturally, we are concerned about human beings, people, their health, rights, welfare and wellbeing. But people are not the one dimensional entities denoted by the labels spewed out by international institutions (‘international’ generally meaning wealthy countries). Instead, I would draw readers’ attention away from these ‘populations’, which almost all African people could be shoehorned into at some time in their lives; many would fall into several. I think it is far more fruitful, as well as a lot less demeaning, to pay some attention to places, for example, large-scale mines in southern Africa, ecological zones, such as Lake Victoria, certain hospitals and facilities that provide various health related services, perhaps even places where people go for cosmetic services and even various traditional practices, such as circumcision. As mentioned, HIV prevalence is low in the North African region, higher in the East African region and highest in the southern region. There are many spatial factors, and the HIV industry does consider them sometimes, but they always view them in terms of what kinds of sexual behavior may be practiced in high HIV prevalence areas.

In his book on the origins of HIV, mainly in Francophone African countries, Jacques Pepin talks about colonial health programs, which he and others sometimes refer to as ‘well meaning’. But, like infrastructure in general, health services were probably intended to enable the smooth running of armies, mines, companies exporting raw materials, such as timber and textiles, also high value goods such as tea. In other words, these ‘benefits’ were not developed, originally, for Africans; they were for colonials, for the colonial power. Mining companies and other big employers may find it good for business to be able to treat endemic illnesses that would otherwise threaten production (just as today, some might argue, funding is provided for diseases that we think may threaten wealthy countries, which was the case with HIV, and perhaps even ebola). Occupational and other private health services, also, may not be subject to the kind of (generally fairly superficial) scrutiny potentially faced by public health services. Pepin argues that healthcare transmission was very important early on in the pandemic, before AIDS was identified and the virus causing it was discovered. But he argues in the introduction that unsafe healthcare has long ceased to be a major factor in African countries. He also argues that almost all transmission, after a certain point in history, became sexual. For him, in a sense, there was an explosion of unsafe sexual behavior, although such a phenomenon has never been empirically described (sensationalist accounts based on high transmission rates, which have been empirically described, do not show that all or most transmission is a result of sex).

Despite the popularity of HIV related PR materials pointing the finger at certain people and their sexual behaviors, disease epidemics, HIV included, are not entirely determined by what individuals do. There are important environmental factors, ‘environmental’ being a very inclusive term indeed; and there is the pathogen itself, which I have less to say about. I have been concentrating to a large extent on spatio-temporal factors of the kind hinted at above because theories about ‘populations’ don’t seem to be very helpful, in addition to being highly prejudiced. Fishermen, miners, migrants, transport workers, teachers, soldiers and various others have at some time had the finger of blame pointed at them by the HIV industry. But often, a little background reading suggests that there is something other than their individual behavior, even their sexual behavior, that relates to high HIV prevalence. For example, HIV prevalence is very high in fishing communities, but it is not clearly highest among the fishermen themselves. Some research has suggested that proximity to and contact with Lake Victoria is associated with very high prevalence, not so much the occupations or behaviors of the people infected. Sex workers in some countries are unlikely to be infected, or at least, a lot less likely than sex workers in African countries (and infections are often a result of injection drug use). Sex workers in African countries may face elevated non sexual risks, such as frequent visits to sexual health clinics, where safety may not be prioritized. Also, some early reports of high rates among transport workers, teachers and healthcare workers may not have paid much attention to non-sexual risks, or they may have exaggerated sexual risks. Even some of the figures for prevalence have been exaggerated at times.

The HIV industry does, as I have said, pay attention to some of the factors that I would argue are important. It’s just that their starting point is how various phenomena clearly relate to people’s sexual behavior, without demonstrating that HIV is almost always transmitted sexually. People close to Lake Victoria may be more susceptible to HIV because of an endemic parasite called schistosoma. This means that sexual transmission of HIV is very significant, but there is no need to impute any kind of ‘deviant’ sexual behavior or any kind of ‘traditional’ practices that may (or may not) impinge on people’s sex lives. Just ordinary sex would be enough, sex in ordinary quantities, with ordinary people. Of course there are sex workers in Africa, just as there are sex workers everywhere. There are people who have a lot of sex in Africa, just as there are such people everywhere. But most people don’t have a lot of sex, and some have none at all. Regression to the mean doesn’t cease when you reach sub-Saharan Africa and sex is one of those things that most people can’t engage in to extreme levels. Whereas it is hard to imagine a limit to the amount of money one person can earn, there are several limits to how many different people one can have sex with, what kinds of sex, how often, etc. (I’m following Nasim Taleb’s concepts of Extremistan and Mediocristan; sexual behavior is probably not susceptible to black swan events.)

To finish Part II, HIV in Kenya is not just about individual behaviors, it is also about places, such as Lake Victoria, Turkana, Nairobi and other cities, and parts of those cities. The obsession with ‘African’ sexual behavior, which seems to have started with the eugenics movement, not with the discovery of HIV on the continent, has been entirely fruitless and highly stigmatizing. But the knowledge that certain places are clearly dangerous has yet to be translated into a similar obsession with healthcare safety, education about bloodborne HIV or a bit of effort to alleviate the most urgent concerns in the lives of ordinary people.

It’s also important also to consider certain temporalities in Kenya’s HIV epidemic. Pepin and others often mention things like societal breakdowns, urbanization, rapid population growth and the like, often with the implication that these ‘obviously’ explain massive increases in unsafe sexual behavior. But societal breakdowns did not start in the 1980s, no more than sex did (or even media fantasies about ‘African’ sexuality). Some societal breakdowns, such as wars, result in very low HIV transmission (for example, Mozambique, Angola, Sierra Leone, Somalia and others). Many societies are broken down but none of these breakdowns, that I have heard of, have been shown to result in widespread levels of unsafe sexual behavior. Urbanization and high population growth, too, have occurred at many times in many places. In Kenya there have been population growth rates as high as 8 or 9% per annum during the period 1969-2009. But often these high rates of growth were in areas where HIV prevalence never went very high, such as Mandera; some places where HIV prevalence is (or was) high experienced low population growth, such as Mombasa. Kenya’s epidemic is old enough to show that factors involved in the spread of the virus go back a long way and are still extant. Those factors, whatever they are, have eluded UNAIDS, WHO, CDC and other august institutions. But that doesn’t mean they can never be identified and successfully addressed.