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Category Archives: unsafe healthcare

Drugs for All Deemed More Profitable than Circumcision


Demands to roll out mass male circumcision programs, claimed to reduce HIV transmission, date back at least 20 years. Other claims about the ‘benefits’ of circumcision go back centuries. But by the time the programs had started several other interventions had been identified that have a far better claim to reduce HIV transmission.

For example, ‘test and treat’, the practice of putting everyone who tests positive for HIV on ARVs immediately, is claimed to reduce transmission to a HIV negative sexual partner by 96% or higher. (Note, 90 is something of a magic number in UNAIDSland at the moment, with their 90-90-90 strategy replacing various other magic numbers conjured up in the past.)

PrEP, the practice of giving ARVs to HIV negative people who are thought to be at risk of infection with the virus, is also claimed to reduce transmission to a HIV negative partner by 96%.

If the number of HIV positive people in the world is something around 30 million, depending on which estimates you use, and about half of them are claimed to be on ARVs already, there are still around 15 million who can benefit from ARVs. That’s worth, say, a few billion dollars.

Although a lot of those opposed to mass male circumcision don’t seem to realize this, many of those promoting circumcision are the same people who promoted behavior based programs, particularly those with an emphasis on ‘abstinence’. Those programs, although they never completely died out, were a disaster. Even the people formerly pushing them now admit that they probably had no impact on HIV transmission. But they wanted to find another source of funding to replace the vast amounts that used to go into ‘prevention’, a lot of which was spent on behavior based rubbish.

Circumcision seemed like the answer because the number of people who could be targeted for circumcision could run into hundreds of millions. Every year millions more male children would be available to keep the programs profitable.

At first the promoters claimed they were only targeting sexually active adults, but they quickly found that most of them didn’t want to be circumcised. It was much easier to recruit children and now they can turn their attention to infants.

But with test and treat, coupled with PrEP, how can the circumcision enthusiasts still claim that there is any benefit to the operation? They need to target almost the entire male population in countries where circumcision is not widely practiced. They must carry out the operation on about 75 men for every one claimed reduction in HIV transmission.

The other interventions, test and treat and PrEP, are claimed to be targeted at those most at risk. Let’s take a look at who is thought to be most at risk, and see just how many hundreds of millions of people that involves, who would need to be taking these drugs for the rest of their lives in the case of test and treat, and for as long as they are thought to be at risk for PrEP.

In western countries there are few groups who are thought to be at risk. The biggest group is men who have sex with men. The second biggest group is injecting drug users. But aside from commercial sex workers, who are given some choice in prevention options in many rich countries, there are not many others.

The picture is completely different in southern and eastern African countries, with high prevalence and/or large numbers of people infected with HIV. This article about a PrEP program in Kenya says the groups of people claimed to face the highest risk of being infected include:

  1. Discordant couples (where one partner is HIV positive and one is HIV negative)
  2. People who frequently contract sexually transmitted infections
  3. People who are said to be unable to ‘negotiate’ condom use
  4. People who frequently use post-exposure prophylaxis (a short course of ARVs for people who suspect they may have been infected, taken within 72 hours of contact)
  5. People who share injecting equipment

Out of the estimated 77,600 new infections in Kenya it is not clear how many arose among any of the listed ‘risk’ groups. High prevalence countries tend not to trace contacts, assuming that the bulk of transmissions (about 90% if you exclude infants said to have been infected by their mothers) were a result of heterosexual intercourse.

You could easily add other risks to the above list, for example (most of the following are a risk in developing countries although 7, 10 and 12 are likely to be more common in rich countries):

  1. People who have given birth in a health center/clinic
  2. People who have given birth at home, or anywhere other than in a health center/clinic
  3. People who have received birth control injections
  4. People who have had injections, blood tests, transfusions, dental care, infusions, etc
  5. People who have had operations that involved piercing the skin, major or minor (including circumcision)
  6. People who have received some forms of traditional healthcare that involved skin piercing
  7. People who use injected appearance or performance enhancers (eg botox, steroids, etc)
  8. People who get their head shaved or where skin is pierced and/or weakened by processes
  9. People who receive manicures, pedicures, etc
  10. People who have body piercings
  11. People who practice scarification and other practices
  12. People who get tattoos

Of course, with the second list, you could warn people about the risks and clean up health centers, cosmetic establishments and anywhere skin piercing occurs (the list is surprisingly long). This would seem preferable to putting almost everyone in a population on expensive drugs for many years.

But UNAIDS, CDC, WHO and other establishments object to calls to warn people about the risks they face in health and cosmetic facilities in developing countries. They warn some people from rich countries about the risks in poor countries but they refuse to warn people in poor countries.

Even concentrating on the risks listed in the Kenya article it is easy to identify many millions of people who could be said to need the $775 per annum PrEP, which is the estimated cost of the drugs alone (I don’t know what other costs there may be).

So you can see the attraction for the HIV industry. If there were only 5 million people requiring years of ARVs, for some, a lifetime of ARVs, that’s several billion dollars for Kenya alone. There are countries with higher prevalence and others with higher numbers of people infected than Kenya.

With only a few billion dollars for mass male circumcision, with its 1.3% absolute risk reduction, or even the claimed 60% relative risk reduction, drugs for the sick and the well seems like a far more lucrative strategy. Even if the benefits realized for mass male circumcision far exceed those unlikely claims, they can’t come close to the claimed benefits of test and treat and those of PrEP.

One problem is that you can’t roll out PrEP for many of the groups claimed to benefit. For example, in discordant couples the positive partner should already be receiving ARVs. People who share injecting equipment could be better served by a clean syringe and needle program. There may be other examples, where overlapping PrEP and test and treat might raise eyebrows among the more scrupulous in the industry.

And it would be perverse to give PrEP to people while they still attend clinics and other places where skin piercing procedures take place without warning them about the risks and also ensuring that those places start to abide by strict infection control regulations that people in rich countries (and rich people in poor countries) enjoy.

If PrEP and test and treat strategies are as wonderful as we are told, let’s hope they do as well in the field as they did in trials. But let’s also get rid of these silly mass male circumcision programs. We no longer have to pretend that they will reduce HIV transmission, or even pretend that that’s why they were rolled out in the first place. Worse still, the profits are orders of magnitude lower than the drug based strategies.

HIV: Cuba’s Success and Uganda’s Failure


Uganda is frequently mentioned in glowing terms in articles about HIV, especially in relation to the late 80s, 90s and early on in the 2000s. In contrast, Cuba is rarely mentioned in glowing terms, although the percentage of 15-49 year olds infected with HIV (prevalence), at 0.3%, is 23 times smaller than the same figure for Uganda, which stood at 7.1% in 2015 (all HIV figures from UNAIDS).

In fact, one could suggest that Uganda never got to grips with the epidemic. They still can’t explain why so many people, said to face a low risk of being infected with HIV, have seroconverted over the past several decades. Despite huge amounts of research, money and other resources being thrown at the country, the bulk of published research on HIV in Uganda seems to be focused on assumed sexual behavior and assumed sexually transmitted HIV.

Little or no international funding went into the HIV epidemic in Cuba. The country worked hard to research the epidemic, even before the first HIV positive person was identified there, several years before. Luckily, the country had a well developed health service, with more doctors per patient than any other high prevalence country (including the US). Indeed, the US (where an estimated 1.2 million were living with HIV in 2013) seemed intent on ridiculing Cuba’s approach to the virus.

Some of the criticisms were directed at claimed human rights aspects of Cuba’s achievements. It was often stated or implied that men who have sex with men were especially targeted by, for example, Cuba’s imposed ‘quarantine’. The quarantining started when little was known about the course of the illness, but it was relaxed once more was known. A number of personal accounts, some from men who have sex with men, now make it clear that many of the people quarantined are grateful to have received the care they got at the ‘sanitaria’ (there are links to other similar articles from this article).

An article by Tim Anderson finds that the quarantine did not target men who have sex with men; it also finds that other procedures were carried out in accordance with international guidelines. Anderson notes that Cuba was ‘more thorough’ in their testing and tracing procedures. Cuba has continued to make improvements in how they deal with the epidemic, which is a low level one, with men who have sex with men being the most affected group.

Sarah Z Hoffman refers to Cuba’s HIV program as ‘the most successful in the world’. Cuba approached HIV with the aim of reducing the likelihood of those infected going on to infect other people. That may sound like an obvious aim, but the greater thoroughness of Cuba identified by Anderson can be contrasted with a reduction in contact tracing in many countries, where it was claimed that certain groups were being unfairly targeted by such measures.

Cuba also started providing all HIV positive people with antiretrovirals in 2001, which they produced themselves as generic versions. Other countries had to wait a long time before they could provide more than a small fraction of HIV positive people with ARVs, and they had to pay astronomical amounts of money for them for years (although the costs are far lower now).

Hoffman writes “HIV infected people must provide the names of all sexual partners in the past six months, and those individuals must be tested for HIV. People found to have any sexually transmitted disease must undergo an HIV test as well. Voluntary HIV screening is encouraged.”

This is one of the places where practices in Cuba differ from practices in most other countries. This is called ‘contact tracing’ and it’s a vital tool of infection control. But in most countries people can claim anything they wish to about their sexual partners, that they have never had sex, that they have only engaged in heterosexual sex, that they have never injected drugs, etc. If people can withhold such information then contact tracing is impossible.

(My previous post is about a rare and valuable contribution to the history of HIV in Africa from John Potterat’s book ‘Seeking the Positives’, much of which concentrates on his work on HIV and STI epidemiology in the US. There’s a link to the chapter here. The approach the US adopted towards HIV could hardly have been more different from that of Cuba. Unfortunately, most other countries, certainly most poor countries, wedded themselves to the US, till death…etc.)

As a result of not tracing contacts, or of not doing so very assiduously, countries like the US, with extremely high transmission rates in certain groups, have never got their epidemic under control. In common with Cuba, the largest proportion of new HIV infections now is among men who have sex with men. Unlike Cuba, there is also a large injecting drug population in the US. But where contacts are not traced, they can not be offered the same opportunity to avoid infection if they are negative, or avoid infecting others if they are positive. Nor can they be ‘connected to care’ as quickly as possible.

In fact, many of the things western countries write copiously about, such as early testing and treatment, universal testing, elimination of mother to child transmission, universal access to treatment, were achieved in Cuba years ago, but have never been fully achieved even in some western countries. Where HIV prevalence is highest, in southern and eastern African countries, some of those achievements may not be realized in our lifetime.

Unfortunately for the worst affected countries, the rights of individuals are claimed to be foremost. Their contacts, past and future, are not treated as individuals. If the individual has multiple partners and chooses not to reveal that they engage in high risk practices, that’s considered to be the individual’s business. If the individual has had no sexual partners, or no HIV positive sexual partners, then the source of their infection needs to be identified. But in high prevalence African countries tracing of non-sexual contacts is rare. What you do find a lot of in research is findings referred to as ‘biased’, because the researcher expected every HIV transmission to be a case of sexual transmission.

(Despite the apparent desire of most countries to protect people’s individual rights in relation to HIV, this approach seemed to go out the window when the virus involved was ebola. Some ‘infection control’ measures seemed to involve groups breaking into people’s houses, forcing them into shabby health facilities, burning their property in public, spraying their houses, breaking up families and communities, etc. Who knows what approach will be taken to the next headline grabbing epidemic.)

So why all the attention and resources for a country that appears to have lost control of HIV a long time ago, and why all the rhetorical questions about Uganda, how their ‘success’ can be replicated, etc? More importantly, why so little attention for Cuba, and why is it so belated? We can learn a lot from both countries. Instead, we should be asking what Cuba did right, and continues to do right, but what Uganda did wrong, and continues to do wrong.

Cuba’s approach to HIV may have been the most successful anywhere. Some would go further and claim that Cuba may be the only country that was seriously threatened by the virus, but gained complete control over the epidemic early on, and retained that control. In the sphere of human rights, also, Cuba has made a lot of progress. Uganda, on the other hand, continues to move in the opposite direction in the fields of public health, human rights, HIV, political stability, economy, etc.

Long Standing De Facto Gag Rule on HIV in ‘Africa’


The gag rule about abortion is not the only gag rule, and even the ‘global gag rule’ never went away in developing countries. Organizations running sexuality, HIV, reproductive health and other programs have long had to cover up anything that might appear to show a pro choice attitude of any kind.

They knew that funding, especially from the US, would be threatened by even appearing to be pro choice in any way.

But there is a much more pervasive gag rule relating to HIV in high prevalence countries, all of which are in Africa. The history of HIV has some very shocking aspects that you won’t hear much about through reading some of the better known literature.

A chapter from John Potterat’s Seeking the Positives, entitled ‘Why Africa?: The Puzzle of Intense HIV Transmission in Heterosexuals‘ is available free of charge on ResearchGate.net. Potterat delves into a long list of the things that those researching into and writing about HIV are not allowed to speak of openly, even when they are reporting findings from scientific research.

For example, many researchers and other professionals believe in African ‘hypersexuality’ as an explanation of hyperendemic HIV (which is only found in African countries). This is just a prejudice, but it informs the bulk of HIV writings in scientific journals. Here’s a quote from Catherine Hankins, who was an epidemiologist at UNAIDS, that would make a Trumpite redneck proud.

Many assume that HIV really is a threat to all, regardless of sexuality, location, circumstances, etc, and don’t realize that there was a decision made to present the virus that way to appease those who felt they were being stigmatized as being most at risk; Potterat refers to the ‘consensus’ emanating from the WHO and CDC in 1988, and elsewhere to ‘consensus epidemiology’. Facts have never had as high a status as consensus where HIV in high prevalence countries is concerned.

People who have never been to a high HIV prevalence country could be forgiven for accepting that the risks of HIV transmission from unsafe healthcare and other skin-piercing practices are extremely low. But this is also claimed by people who live and work in high prevalence countries.

In fact, foreigners working for big institutions such as UN bodies, are issued with a specially written booklet warning them to avoid healthcare facilities that haven’t been approved by them. Yet people living in these countries, who must avail of unsafe facilities are not warned.

Potterat notes that he and his colleagues were told by a high ranking official ‘not to tell African people’ that their healthcare facilities are so dangerous that foreigners are warned not to use them.

In reality, Potterat’s recommendation that people in high HIV prevalence African countries be warned about the risks they face, and that conditions in health facilities be improved, is a very modest one. People have a right to such information, and to safe facilities; so why the reluctance to inform them?

People have a right to accurate, accessible, appropriate health information under international human rights law. Politically motivate agreements about what to tell the public and, more importantly, what to tell people in high HIV prevalence countries, do not constitute such health information.

Reluctance, apparently, partly stems from the fact that CDC, WHO, UNAIDS and the like think it will ‘water down’ their ‘messages’ about ‘safe’ sex. In other words they want to continue lying about ‘African’ sexuality, as well as about unsafe healthcare. They don’t want to be exposed as having spent three decades not addressing the main drivers of HIV, and instead lying about sexual behavior in high HIV prevalence countries. Hankins uses that argument in the BBC article linked above.

These revelations from Potterat’s book are all shocking because we are left with the question of how many people would be alive today if they had known what these international health institutions all knew so long ago. Such questions were asked about the inaccurate information spread by Mbeki’s regime in South Africa, so why not ask the same of international health institutions, universities, donor countries and others?

Tens of millions of people have been infected with HIV in high prevalence countries since the 80s; how many of them would be HIV negative now if they had known the risks of unsafe healthcare? Half of them? More than half? Perhaps we’ll never know. But the lies are well documented in Potterat’s writings and must be followed up by the scientific community.

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


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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 15 months, September 2013 to December 2014 (see Figure 2b in [4]). These sequences can be presented as branches in a “tree” (see below, Figure 1; this tree uses most of the same sequences as reference 4, but suggests transmission took several years rather than 15 months). 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 2018; 66: 1733-1741. Available at: https://pubmed.ncbi.nlm.nih.gov/29211835/ (accessed 24 February 2021).

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?


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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

 

 

 

 

 

HIV and the Real(ly Lucrative) Risks


In an article entitled the ‘real’ risks of sex with someone who has HIV, the authors concentrate on a handful of considerations, but don’t mention some of the most important risks. They seem intent on advertising (or advertorialing) HIV drugs, like a lot of these media articles. Also, the article is about a HIV positive American celebrity, so there may be no real intention of informing people about HIV.

Anyhow, the gender of the HIV positive person is not mentioned. In Western countries, very few males are infected through heterosexual sex. The majority are either infected through male to male sex or through injected drug use. Of course, many may claim to have been infected through heterosexual sex, and even believe they were. But the chances of a man being infected by a HIV positive woman through penile-vaginal sex are so low that there are few documented instances, where there is no possible doubt about the source of the infection.

The position is completely different for women. It is perfectly possible for a HIV positive man to infect a HIV negative woman through penile-vaginal sex, although the risk is not especially high. There are many other factors that can increase the risk, and they are too numerous to list, but the overall health of both parties may be an important one. This is not just about sexual health, but rather the state of each person’s immune system at the time.

Anal sex is also a significant risk for men and for women. But the risk for a man who never engages in receptive anal sex, only insertive anal sex, remains far lower, and this is the case for anal sex with men and with women. The receptive partner, whether male or female is at very high risk. A lot of people wouldn’t admit to engaging in anal sex of any kind, and they may not always remember what they did and didn’t do.

There are even highly complex reasons why someone may be more susceptible or more infectious at a given time, or under certain circumstances. Too little is known about these matters and they will probably remain little understood until someone finds out how to make money out of such knowledge. Concentrating on therapies is a lot easier, because they are already the source of incredible amounts of money, even by pharmaceutical industry standards.

If you don’t know the most significant risks of being infected with HIV, or of infecting others, you can’t protect yourself from them. So this Yahoo! article is very dangerous. But it is merely a function of the relationship between Big Pharma and big media. In the end, such sources of dis/information are not the best way of protecting yourself or others from HIV and other diseases. Broaden your research base, open your eyes, and think.

Zimbabwe: Thought Embargo at HIV Inc to Continue Indefinitely


The Zimbabwean health minister, David Parirenyatwa, has exposed his complete ignorance about the country’s HIV epidemic by claiming that there is ‘rampant homosexuality’ in prisons, and that this is making an especially large contribution to high rates of HIV transmission in these institutions.

Naturally, there are some men who have sex with men in prisons, and not just in Zimbabwe. But that is not just because men are more likely to have sex with men when incarcerated for lengthy periods with men, denied conjugal visits and other rights. It’s also because having sex with someone of the same gender can itself attract a prison sentence.

However, what the health minister fails to realize is that there tend to be very poor health services in prisons. If he had inspected health services in prisons he would have come to a very different conclusion. Indeed, had he inspected health services outside of prisons he would also have come to a different conclusion about Zimbabwe’s massive HIV epidemic.

Prevalence in Zimbabwe had already reached about 15% in the early 1990s (compared to about 1% in South Africa). But it shot up to almost 30% before the end of the decade, then dropped back to early 1990s levels in less than 10 years. The figure has remained at roughly half its peak for the last decade or so.

The death rates required to bring prevalence from 30% to 15% in less than 10 years must have been phenomenal. Did the esteemed (and I’m sure astute) Parirenyatwa notice a sudden rise in prison populations during the 1990s, followed by a profound drop, with a subsequent flatlining thereafter? Or a sudden rise in male to male sex? Or a sudden rise in ‘unsafe’ sex among heterosexuals?

I don’t think so. But I also doubt if the health minister has a clue what was going on in the country’s health services then, or perhaps now. Massive increases in HIV transmission during the 1990s was very likely a result of a decrease in levels of safety in health facilities, along with a probable increase in usage of health facilities.

Minister, HIV is most efficiently transmitted through unsafe skin piercing procedures, such as injections with reused injecting equipment, surgical instruments, etc, also through unsafe body piercing and tattooing, and even through unsafe traditional practices, such as scarification, blood oaths and others.

Just how unsafe would cosmetic and traditional practices be in a prison? We can only guess. How safe would they be elsewhere? It’s unlikely anyone has checked. If they have, they would have found it difficult to publish the findings.

It’s easy to blame high HIV prevalence on ‘promiscuity’, male to male sex, carelessness, stupidity, malice and other phenomena, so beloved by journalists and others milking the HIV cow, far too easy. But ministers, journalists, academics, and even those who have reached lofty heights in international NGOs and the like, are still permitted to consider the roles of unsafe healthcare, cosmetic and traditional practices. I invite them to do so.

‘African’ Sexuality: Consensus or Prejudice?


An article by Damien de Walque, entitled ‘Is male promiscuity the main route of HIV/AIDS transmission in Africa?‘, seems curiously behind the times. He refers to the “pervasive if unstated belief in the HIV/AIDS community…that males are primarily responsible for spreading the infection among married and cohabiting couples”.

Disturbingly, de Walque goes on to conclude that, because women are as likely as men to be the infected partner in discordant relationships (where only one partner is HIV positive), both male and female promiscuity must be the main route of transmission. This is by no means the only possible conclusion; far more women than men are infected with HIV in high prevalence African countries, but this could be a result of other risks, particularly non-sexual risks.

However, women being almost as likely as men to be the infected partner in discordant relationships was not a new discovery when de Walque was writing in 2011. Gisselquist, Potterat, Brody and Vachon published an article in 2003 entitled ‘Let it be sexual: how health care transmission of AIDS in Africa was ignored‘, which presents evidence from the 1980s showing that women are almost as likely as men to be the positive partner in discordant relationships. They also show that neither is promiscuity the main route.

The article by Gisselquist et al looks back at papers from the 1980s demonstrating clearly that the bulk of HIV transmission in African countries is not sexually transmitted. Data collected about sexual behavior does not support the view that Africa is exceptional. Rather, data about other risks, such as unsafe healthcare, cosmetic and traditional practices was either not collected, or was ignored.

Even the abstract gives a good sense of what was going on in the 1980s (and is still going on). I’ll cite it in full, adding italics for emphasis:

“The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in African adults emerged no later than 1988.We examine evidence available through 1988, including risk measures associating HIV with sexual behaviour, health care, and socioeconomic variables, HIV in children, and risks for HIV in prostitutes and STD patients. Evidence permits the interpretation that health care exposures caused more HIV than sexual transmission. In general population studies, crude risk measures associate more than half of HIV infections in adults with health care exposures. Early studies did not resolve questions about direction of causation (between injections and HIV) and confound (between injections and STD). Preconceptions about African sexuality and a desire to maintain public trust in health care may have encouraged discounting of evidence. We urge renewed, evidence-based, investigations into the proportion of African HIV from non-sexual exposures.”

Consensus among influential experts should be based on available data; not only did these experts ignore a lot of available data, they failed to collect a lot of data that could have led to a very different consensus. But several long-held preconceptions, for example, about ‘African’ sexual behavior, may have had undue influence on the consensus of these experts. It is these preconceptions that I am interested in.

By claiming that UNAIDS is going to change its name to UNAZI (as far as I know, they are not going to), I wished to draw attention to the fact that the still current claim that HIV is almost always transmitted via heterosexual contact in African countries (but nowhere else) is based on the preconceived views of some very prejudiced ‘experts’. UNAIDS acquired a consensus of experts who had decided, before the institution was established, that they were going to concentrate almost exclusively on heterosexual transmission, and diminish the role of unsafe healthcare and other non-sexual transmission routes.

The big lie about HIV in ‘Africa’ is that 80% (sometimes 90%) of prevalence is from ‘unsafe’ heterosexual sex, and most of the remaining 20% (or 10%) is from mother to child transmission. This lie emerged in the 1980s, from ‘experts’ who knew that it was a lie. The entire HIV industry is still based on this lie three decades later. As a result, most African people are unaware that unsafe healthcare, cosmetic and traditional practices may be a far bigger HIV risk than sexual behavior.