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Category Archives: VMMC

Drugs for All Deemed More Profitable than Circumcision

Comments Off on Drugs for All Deemed More Profitable than Circumcision Posted by on March 22, 2017

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.

behavioral paradigm, circumcision, HIV, institutional racism, male genital mutilation, mass male circumcision, unsafe healthcare, VMMC , ,

Depo Provera and Circumcision: Violence Against Women Masquerading as Research

1 Comment Posted by on July 1, 2015

Although there are plenty of instances of institutionally sanctioned violence against women, this blog post is about two very prominent instances: mass male circumcision programs [*Greg Boyle, cited below; one of the most up to date publications on the subject, which cites many of the seminal works] and the aggressive promotion of the dangerous injectible contraceptive, Depo Provera (DMPA).

Why are mass male circumcision (MMC) programs instances of violence against women? Well, three trials of MMC were carried out to show that it reduced female to male transmission of HIV. They were show trials, with the entire process monitored to ensure that it gave the results that the researchers wanted. These trials have been cited countless times by popular and academic publications.

Less frequently cited was a single trial of MMC that was intended to show that it reduced male to female transmission of HIV. None of these four trials were independent of each other and the female to male trials produced suspiciously similar results, despite taking place in different countries, with ostensibly different teams. But the single male to female trial showed the opposite to what the researchers wanted: circumcision increased HIV transmission, considerably.

During all four of the trials, male participants were not required to inform their partner if they were found to be HIV positive, or if they became infected during the trial. If there had been any ethical oversight, those refusing to inform their partner would have been excluded from the trial. This is what would have happened in western countries, including the one that funded the research, the US.

Given that many women and men believe that circumcision protects a man from HIV, these MMC programs are giving HIV positive men the means to have possibly unprotected sex with HIV negative women. Many women and men were infected with HIV during the four show trials and almost all of those infections could have been avoided. How participants became infected during the trials has never been investigated, which is not only unethical, but also renders the trials useless.

Despite Depo Provera use substantially increasing the risk of HIV positive women infecting their sexual partners, and the risk of HIV positive men infecting women using the deadly contraceptive, this is the favored contraceptive method for many of the biggest NGOs (many of the biggest NGOs are engaged in population control of some kind). Therefore, its use is far more common in poor countries (especially among sex workers) and among non-white populations in rich countries.

These two instances of violence against women (and men) are funded by the likes of CDC, UNAIDS and the Gates Foundation. Many research papers extolling the virtues of MMC and Depo Provera are paid for by such institutions, copiously cited by them in publications, and constantly wheeled out as examples of successful global health programs. Yet, they are both responsible for countless numbers of avoidable HIV infections.

There is currently a lot of institutional maundering about violence against women and certain instances of it, but some of these same institutions are taking part in the perpetration of it; they are funding it, making money and careers out of it, promoting themselves and their activities on the back of what is entirely unethical. Why do Institutional Review Boards, peer reviewers and academics, donors and others seem happy to ignore these travesties? Who is it that decides that this is all OK, when it clearly is not?

Why are these not considered to be unethical: aggressively promoting the use of a dangerous medication, and an invasive operation that will neither protect men nor women? Is it because those promoting them are making a lot of money out of them, because the victims are mostly poor, non-white people, because the research and programs take place in poor countries, because ethics is nice in principle but too expensive in practice…? Or all of the above and more?

* Boyle, G. J. (2013). Critique of African RCTs into male circumcision and HIV sexual transmission. In G. C. Denniston et al. (Eds.), Genital cutting: Protecting children from medical, cultural, and religious infringements. Dordrecht, The Netherlands: Springer Science+Business Media doi: 10.1007/978-94-007-6407-1_15

behavioral paradigm, blood, circumcision, HIV, iatrogenic, male genital mutilation, mass male circumcision, VMMC , ,

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

1 Comment Posted by on June 15, 2015

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.

circumcision, ebola, male genital mutilation, mass male circumcision, media racism, nosocomial, unsafe healthcare, VMMC ,

We do them in Black for 14.99

1 Comment Posted by on November 12, 2014

I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”

The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.

You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.

‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.

So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.

The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.

The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.

The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.

Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?

Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.

The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.

To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.

AIDS, circumcision, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

Uganda’s HIV Prevention and Control Act May Fall Foul of Itself

1 Comment Posted by on October 25, 2014

The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.

It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.

But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.

In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don’t Get Stuck With HIV site.)

The act makes no explicit mention of non-sexual transmission through healthcare, cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.

The above incidents raise questions about the act’s definition of ‘informed consent’, which requires that people be given “adequate information including risks and benefits of and alternatives to the proposed intervention”. Were mothers informed about all of  the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?

Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.

The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.

Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn’t always protect them from conviction.

Part one of section 45 reads: “All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification”; part three reads: “A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction…”.

So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.

AIDS, blood, circumcision, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

Revised History of HIV in Kenya – Part V – UNAIDS’ Rorschach Hypothesis

Comments Off on Revised History of HIV in Kenya – Part V – UNAIDS’ Rorschach Hypothesis Posted by on August 17, 2014

As I said in earlier posts, HIV arrived in Kenya and remained unnoticed until the 1980s. It is said to have spread rapidly throughout the 80s, especially in certain places (such as Nairobi, Mombasa, Nyanza province and perhaps a few others), but also to have remained low in other places (such as the North and Northeast). The rate of new infections, incidence, peaked in the early to mid 1990s and declined thereafter. So prevalence peaked in the late 90s or early 2000s, with high death rates, which may have peaked in the mid 2000s. The epidemic has a long early years tail (1950s-1980s), a humped back, possibly very humped, and a longish neck. Perhaps the curve resembles an outline of a diplodocus, complete with a little bump where the head should be, but just a small head.

With prevalence peaking at a little over 10%, but only for two or three years, the period of high transmission or incidence would have been six or seven years previously (going backwards again, for a moment). That suggests something catastrophic in the mid to late 1980s and early 1990s that was responsible for much of this rapid transmission. Whatever that something was, it didn’t result in rapid spread of HIV before the 1980s, and it ceased in the 1990s. It also ceased to result in rapid spread of HIV after a brief few years. Does that sound like sexual behavior to you? It does to the HIV industry, who have been trying to redescribe similar phenomena in all high HIV prevalence African countries.

So the diplodocus is not the only kind of epidemic curve; there are several dinosaur-like curves that you can spot using UNAIDS data. Many of them look very similar, but there are some whose backs rise two or three times higher than any of those found in East Africa, for example Zimbabwe. A few more countries show an epidemic that exploded in the 1990s but haven’t dropped yet, such as Swaziland and Lesotho. The Dinosaur is also a good metaphor for some of the institutions and international NGOs that have systematically resisted one of the best arguments for universal primary healthcare ever (HIV, that is), and continue to resist it to this day. HIV is almost all a matter of individual sexual behavior, they say.

But I did mention being drawn to spatial and temporal factors, rather than ‘populations’. Even in my first attempt at characterizing Kenya’s epidemic it was clear that there wasn’t really a ‘national’ epidemic. Instead, there were places where HIV prevalence was exceptionally high, and even more places where HIV prevalence was low. Over time, there were places, high and low prevalence, where the curves looked nothing like dinosaurs. They were more like pancakes in low prevalence areas, sometimes with a small piece of fruit under them, and Mexican hats in high prevalence areas. Could this data really describe sexual behavior over time? I was skeptical, not believing that almost all HIV could be sexually transmitted, as the HIV industry was claiming.

Then it was confirmed to me that HIV is frequently transmitted through unsafe healthcare, cosmetic and traditional practices, such as reused syringes and other equipment and practices in all three scenarios, with the second and third involving razors and other sharp objects that are used to pierce the skin, often the same ones over and over again, without any attempt at sterilization. Reasonable people were arguing that various kinds of bloodborne transmission were the only phenomena that could explain the Mexican hats. That accorded well with what I could glean from the literature. It just doesn’t accord with what the HIV industry insists: we know it’s all about sex, they insist, even when you present instances where it couldn’t possibly be.

I can give you about 50 reasons why I don’t believe HIV is entirely a matter of sexual behavior without even putting much thought into it (I’ve already written the list). But here are 10, with supporting links, so you can follow them up if you are interested. I’ll supply more in Part VI, perhaps even the rest, I’m not sure yet. Many of the reasons I give overlap with the factors involved in HIV transmission that I listed in Part IV, so if you wondered about any of them, you’ll probably be able to match the two lists, eventually. I may even merge them some time, but not now.

1 Prevalence is often higher among rich people. Consult the Demographic and Health Survey (DHS) for most African countries with serious HIV epidemics and you’ll find this. There is a table of HIV prevalence by wealth quintile that I drew up and it is available on a linked blog post I wrote recently.

2 Prevalence is often higher among better educated people. Again, the DHS gives data on this for all high HIV prevalence countries, but here’s a graph with some of the data in a table.

Education focus countries

3 High prevalence often clusters around transport infrastructure. Here’s a wonderful map of Africa where you can see why there are the several HIV regions I mentioned in an earlier part. But notice that ‘spatial accessibility’ or ‘friction’ that they mention do not explain all the regions. West Africa has a less serious epidemic than both East and southern Africa, yet there is good transport infrastructure there.

4 High prevalence often clusters around big employers, such as mines, plantations, etc. But miners and those employed in large numbers face other threats, such as employer supplied healthcare, public health programs, tests, checkups, STI programs and whatever else. Some may face additional sexual risks when they spend 11 months of the year in an all male hostel, but anyone who thinks that this sub-human treatment only impacts on victims’ sexual behavior needs psychiatric assessment.

5 Prevalence is usually higher in urban areas (where non-sexual risks are also higher). But there are multiple differences between urban and rural areas, only some of which relate to sexual behavior. The HIV industry loves going on about ‘sexual networks’, and not just in African countries. But what about the appalling conditions most urban dwelling people experience when they are born in a city or when they move to one? Slums are dangerous places, where children die of water borne diseases that cost a few cents to cure because what they need is clean water, to ensure they don’t get any of a multitude of waterborne diseases. Babies and children die of pneumonia and various respiratory problems, again, easily avoided and treated. But even if you pump a child full of available vaccines and send them back to the same environment, many of them will just die of something else. Adults die of all kinds of things as well, often as a result of the terrible living conditions. Many die or are disabled by road traffic accidents and other kinds of serious injury. Slums, where about 75-80% of Kenya’s urban dwellers live, are dangerous. Does anyone who has thought about it really think the only risks they face are sexual?

6 Prevalence is usually lower in rural areas (where non-sexual risks are also lower; have a look at any DHS). This is not to say that people don’t face hazards. They also don’t receive the benefits of public health programs that are available to people in the cities. Of course, this can protect them from healthcare associated HIV and other diseases but many vaccines work well, a lot of common diseases can be prevented or cured. However, when it comes to HIV, rural dwellers seem to be a lot better off, and inaccessibility of healthcare facilities may have protected them, at least in the recent past. My guess is that while some may be involved in ‘sexual networks’, just as people all over the world are, these do not explain everything.

7 HIV prevalence is not particularly closely related to ‘unsafe’ sexual behavior. For example, DHS figures for sexual behavior among young people in Zimbabwe show how tenuous the connection is. Even the authors were unable to interpret them. But a careful look at sexual behavior figures for many countries show that the numbers engaging in these behaviors tend to be a lot smaller than the numbers not engaging in them. These levels of ‘unsafe’ sexual behavior would not be able to explain the Mexican hat graphs in Nyanza and in Kenya’s major cities.

8 Prevalence is often lower among those who never use condoms. As the linked article shows, condom use is often associated with higher rates of transmission than non use. The authors try to imagine arguments to show why condoms look like they are failing more often than not, but they don’t come up with anything convincing. The figures in the article have been superseded and there’s a more up to date table in a blog a wrote a short time ago. My guess is that condom use is higher among urban dwelling, better educated, wealthier, employed people, and that’s why you get these same patterns for condom use in so many countries. Again, this strongly suggests that HIV is not purely a matter of sexual behavior.

9 HIV prevalence is low in areas where ‘intergenerational’ marriage and sex, that is, between people of very different ages, are more common. I’m linking to a blog post I wrote recently, no point in repeating the whole thing again. The data is from DHS for various countries.

10 HIV prevalence is low in areas where ‘traditional’ practices are more common, such as traditional medicine. These tend to be more common in rural and isolated areas. A possible exception to this is genital mutilation. There are two kinds, only one of which is ‘traditional’. The first kind takes place in a health facility, so that’s usually male genital mutilation. The second kind does not take place in a health facility and includes male and female genital mutilation. It’s hard to say which is more likely to transmit HIV. If mass male circumcision was being carried out in a health facility where infection control procedures were not followed properly, not an uncommon occurrence, then healthcare associated transmission could be very likely, and would be serious; some practitioners are carrying out twenty operations a day, apparently. Traditional circumcision, which has its own hazards, is carried out in entirely unsterile conditions and adverse events are common. But it may be less likely that a HIV positive person is being circumcised along with other initiates. Prevalence should be low among young uncircumcised males. Even if they engage in sex before the wound has healed, those with whom they have sex should also be less likely to be infected. But whether done in a clinic or in a field, genital mutilation is risky. Female genital mutilation generally takes place in unsterile conditions and the risks of some forms may be higher than those faced by males. But female genital mutilation is also more likely to take place in rural areas, where HIV prevalence is lower. It is said that almost 100% of Ethnic Somalis in Kenya’s Northeastern province, both male and female, are genitally mutilated, but HIV prevalence is very low.

HIV probably did very little for years in Kenya. But next to nothing for years is the way to go from being a species jump that should never have survived to being a pandemic. Perhaps a clearer history of how it survived and spread, to explode in the late 80s or early 90s, will tell us more about what is still driving transmission, in Kenya and elsewhere. But there are already many reasons for believing that HIV is not only transmitted through sex. One would want to be seriously disturbed to interpret every factor involved as evidence of sexual behavior.

AIDS, blood, circumcision, ebola, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, VMMC , , , , , , , , , , , , , , , , , , ,

Revised History of HIV in Kenya – Part IV – Diversity

1 Comment Posted by on August 14, 2014

Why is HIV spread so unevenly? In some parts of Kenya prevalence is at ‘hyperendemic’ levels, over 20%, almost 30% in one county. Yet in other counties it is low, 1% or lower. If, as we are constantly told, 80%, even 90% of HIV transmission is a result of unsafe sex (most of the remaining 10-20% being a result of mother to child transmission), what amazing sex lives people in some counties must have (or disgraceful, if you prefer). And what dull (or worthy) lives those in other counties must have, apparently only having sex for the purpose of procreation.

If, on the other hand, HIV is not always a result of sexual behavior, if many people may be infected through unsafe healthcare, even unsafe cosmetic and certain traditional practices, some of the factors involved in HIV transmission rates, low or high, start to make a lot more sense. The list of factors is long (over 40), but the italicized paragraphs are the kind of explanations given by the ‘it’s all about sex’ camp, so they are mostly the same. Yes, some HIV transmission is a result of sexual behavior, nobody is denying that, but some is not. Also, some areas where HIV transmission is high are in need of further study; a priori explanations for high and low prevalence have no place in science (though they seem to receive a warm welcome in a lot of papers on HIV epidemiology).

Christian

Prevalence is often higher among Christians than Muslims, and generally among males than females; not sure why this is so; the majority of HIV positive people in the world live in predominantly Christian countries, meaning that a lot more Christians than non-Christians are infected; why this is so is not clear, although both healthcare access and HIV prevalence are noticeably low in some Muslim dominated countries

Men less likely to be circumcised; also Christians are ‘less restrained’ in their sexual behavior than Muslims

Circumcision

There is no clear evidence that circumcision reduces HIV transmission and it could only influence sexual transmission, at best; however circumcision is risky if carried out in unsafe healthcare facilities or in traditional settings

Circumcision ‘cleaner’ or ‘more hygienic’, although this is a hypothesis, there is no unambiguous evidence

Colonization

The vast majority of HIV positive people live in countries that were colonized by the British. This may relate to healthcare facilities, access to healthcare, health seeking behavior, infrastructure, stability, etc

It’s somehow related to sex

Condom use

HIV prevalence is higher, often far higher, among people who sometimes use condoms than among those who never do, suggesting that HIV risk is not always sexual

Those who are already infected are more likely to use condoms

Culture

Cultural practices such as female genital mutilation (FGM) may increase the risk of being infected, although it increases both sexual and non-sexual risks; yet prevalence among people who practice FGM is generally low, which suggests that there are other factors involved

Increases HIV transmission; if prevalence is low this can be explained away by reference to attitudes towards extra-marital sex, etc

Depo Provera

Increased risk for women taking it and for their partners

Denies that this is a risk and claims that the benefits (prevent conception) outweigh any disbenefits, which don’t exist anyway

Education

Educated people may have better access to healthcare and be more likely to use healthcare

Educated people have access to bigger sexual networks

Employment status

People with a job can afford healthcare, although this may not be safe healthcare; jobs may include healthcare or health insurance; some occupations provide healthcare services;

People with a job have more money and therefore access to bigger sexual networks; despite prevalence generally being higher among employed people, some suggest that unemployed people have little else to do but have sex

Female

Prevalence is usually higher among women, possibly because they have more need to use healthcare services, especially when pregnant and giving birth; they are also more susceptible to sexual transmission

Women are more vulnerable and have less power to make choices; they are usually victims, otherwise they fall under one of the many categories of sex worker

Fertility

Higher fertility may increase healthcare exposure, although it is often associated with low prevalence areas, rural areas, etc

Higher fertility means more unprotected sex

Healthcare

Healthcare may not always be safe, which may explain why countries with good access to healthcare for everyone, such as Botswana, may result in higher HIV prevalence

Sick people, including people with HIV, seek healthcare, which is why healthcare may seem to be associated with higher HIV prevalence; this is especially true of STIs

Hepatitis

HBV and HCV are much more likely to be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices, also injection drug use

Presence of HBV and/or HCV are signs that the person is either promiscuous or an intravenous drug user (or both)

Herpes

Rates can be extremely high in some populations because it is very easy to transmit, sexually and through other routes; it plays a role in being infected with and transmitting HIV but the role is complex

It is a sign that people infected engage in unsafe sex and increases risk of transmitting and being infected with HIV

Inequality

It is neither clear that inequality is associated with higher risk, nor why this may be so

People are more vulnerable to sexual risk, especially women

Infrastructure

Good infrastructure is often associated with high HIV prevalence, which may suggest better access to unsafe healthcare

Good infrastructure gives access to bigger sexual networks

Male

Prevalence is usually lower among men than women, which leaves a question mark over instances of higher prevalence among men when they are found, for example, Muslim men in Kenya; prevalence may be lower because of lower use of health facilities

Men are considered to be mere spreaders of sexually transmitted disease, whether they are rich or poor, urban or rural dwelling, etc

Marriage

Sometimes HIV prevalence is far higher among married than unmarried people and it is not clear why

Married people are less likely to use condoms; they also have extra marital sex, usually the men, then they go home and infect their spouse

Migration

Migration can be for work, which may involve work-related healthcare, which may be unsafe and may not be subject to levels of scrutiny faced by public facilities, however scrutinized  they may be

Migrants, being away from home, either have other sexual partners or visit sex workers; they then return home to infect their spouse

Mobility

Possibly increases access to health facilities, but mobility on it’s own doesn’t seem to explain high prevalence

Mobile people have access to bigger sexual networks

Muslim

Figures vary, with prevalence higher among Muslims than Christians in some countries (eg, Burundi, Rwanda, Mozambique, but not Kenya or Tanzania), also higher among Muslim men than women in others, eg Kenya; not sure why this is so

Men more likely to be circumcised; also Muslims are ‘more restrained’ in their sexual behavior than Christians

National borders

High HIV prevalence has been reported at border areas in the past and rates of unsafe sexual behavior may be higher; but the sex workers and long distance drivers who are said to be responsible for high rates have often taken part in STI eradication programs and may frequently use STI clinics

Long distance drivers have sex with sex workers, then they go home and have sex with their spouses

Occupation – armed forces

Members are unlikely to have any option as to whether they take part in various health programs, tests, etc; healthcare is likely to be free, which means usage is also probably higher

They have access to bigger sexual networks and frequently visit sex workers

Occupation – fishing

Prevalence is high in fishing communities, not necessarily highest among the fishermen; also, very high prevalence seems to be a feature of only some fishing communities, especially lakes; not sure why HIV prevalence is so high

Fishermen do risky work, therefore they are not bothered by sexual risk; also, they spend a lot of time away from home; also, they use sex as a bargaining tool

Occupation – mining

Artisanal mining is not so much associated with HIV so this probably applies to industrial scale mining; the work-related healthcare to which miners have access (they may even be compelled to receive certain health services and tests) may not be safe

Miners work a long way from home and don’t see their family much so they have extra-marital relationships and/or visit sex workers, then go home and infect their spouses

Occupation – teaching

Prevalence has been claimed to be higher and lower among teachers, at different times and places; they probably face similar risks to other public sector employees, whatever those may be

Teachers frequently have sex with their pupils (which may be true, and should be addressed, but it may turn out to have little to do with HIV transmission)

Occupation – transport

Transport workers may use health facilities more; also, they may have been persuaded to take part in STI eradication programs as they have been blamed for all sorts of things; these STI programs may not always have been safe

Transport workers are mobile, which means they have access to bigger sexual networks; then they go home and infect their spouses

Polygamy

Sometimes associated with higher transmission, sometimes with lower transmission, therefore not clear. It is not only practiced by Muslims but also by some tribes and even at least one Christian sect in Kenya

When prevalence is higher, this is because polygamy involves ‘concurrency’; when lower, it’s because men with more than one wife don’t need to have extra-marital sex, or not as much

Population density

Increases pressure on health facilities

Said to increase the size of sexual networks

Population growth

Increases pressure on health facilities

Said to increase the size of sexual networks

Poverty

HIV prevalence is often lower among poorer people, suggesting that they may face lower risk from, for example, unsafe healthcare because of reduced access; however, being poorer means that the only healthcare available may be unsafe

If prevalence is high, poorer women are more vulnerable (to sexual transmission) for various reasons;  if it’s lower, poorer people are less likely to be part of a ‘sexual network’ or their networks are likely to be smaller

Prisoners

There may be some kind of drug use that involves cutting or skin piercing (seems unlikely injection drug use would be common); healthcare is unlikely to be very comprehensive or safe; tattooing and traditional medicine may be additional risks, perhaps also scarification, blood oaths, etc

They have sex with other prisoners, the implication being that the sex includes anal sex; and/or injected drugs or drugs that involve skin piercing; condoms are usually not permitted

Rural

Rural dwelling people have less access to health facilities and infrastructure, which may go some way to explaining why prevalence is usually lower in rural areas

Rural dwelling people have access to smaller sexual networks

Schistosomiasis

This has been shown to increase susceptibility to infection and onward infection, which suggests that some people have sex, not very surprising; but endemic schistosomiasis, which is very cheap to treat, suggests weak healthcare systems

Lots of people having lots of sex with lots of other people all the time: schistosomiasis only adds to what is a ‘known issue’

Sex work

Prevalence among sex workers is low among some sex workers in Western countries unless they also engage in injection drug use but their biggest risk in countries with unsafe healthcare could be their frequent exposure to STI clinics and STI eradication programs; also, a lot of what is referred to as ‘sex work’ is in fact sex between people who are in a relationship or married; many people who are related, in a relationship or married also do business with their partner or relative; ‘gift giving’ is sometimes said to be a form of ‘transaction’ between two people who have sex; this is a very stigmatizing use of the term ‘sex work’ (a bit like the term ‘orphan’, which refers to children in developed countries who have lost both parents, but children who have lost one parent in developing countries; or the word ‘trafficking’ which seems to refer to just about anything that involves sex and that can attract funding to ‘rescue victims’ from)

Sex workers are forced into sex work by poverty, powerlessness, vulnerability, etc, but their consequent risks are high and entirely sexual, unless they are also injection drug users

STIs

STIs do not only suggest unsafe sexual behavior, they also suggest a health system that is failing; some are also transmitted through non-sexual routes, such as herpes and HIV

STIs are a sign that a person engages in unsafe sex

TB

TB is likely to be an occupational disease in deep mines, though mining operations deny this, as they don’t want to compensate those who contract it, pay for their treatment or improve conditions in mines; it increases HIV transmission in both directions

HIV positive people are more susceptible to TB

Tribe

Prevalence is high in some tribes and low in others (high among Luos, low among Somalis in Kenya, for example), which suggests that there may be several factors involved; there are ‘risky’ practices in tribal groups among whom HIV prevalence is low, as well as high (for example, female genital mutilation, which is widespread among Somalis)

‘Tribal’ practices and/or ‘traditional’ practices can be wheeled out on any occasion, either to explain high prevalence or low prevalence; they often involve sex or some form of brutality an are generally inflicted by men on women

Urban

Urban dwelling people have easier access to health facilities and other infrastructure

Urban dwelling people have access to bigger sexual networks

War/civil conflict/refugee camps

Prevalence is generally low during wars and only increases after the war has finished, perhaps because health seeking behavior changes during wars, health facilities become less accessible, money is short, infrastructure is destroyed, etc

If HIV is transmitted it is because people take advantage of the situation, rape and other forms of sexual violence being common; but as prevalence is usually lower it is claimed that sexual networks become smaller, people return to rural areas, etc

Wealth

Prevalence is often higher among wealthier people, suggesting that they may use healthcare more frequently; they may also face occupation related risks that are also non-sexual

Wealthy people can become part of larger sexual networks; they have more opportunities for sex and are more likely to avail of these opportunities

Widowhood

Prevalence among widows and widowers can be very high but it is not clear why

Widows are, in some cultures, inherited, having been widowed because their husband (obviously) died of AIDS; they are ‘cleansed’ (have sex with their inheritor) who may be the brother of the deceased, and infect him; he goes on to infect his other partners, including his spouse

The list above makes no claim to be exhaustive. When there is so much diversity in HIV epidemics within and between countries, why would anyone conclude that almost every factor is, ultimately, a matter of sexual behavior, or somehow relates to sexual transmission? It’s no wonder, given the above list, that HIV positive people are feared, even despised. It is the view that transmission is almost always sexual that results in the stigma UNAIDS and other institutions claim to abhor and pretend to be fighting; they are the source of the stigma. HIV ‘prevention’ programs that include some or all of the italicized arguments above merely spread the stigma.

AIDS, blood, ebola, FGM, HIV, iatrogenic, MGM, VMMC , , , , , , , , , , , , , , , , , , ,

Revised History of HIV in Kenya – Part III – Chronology

Comments Off on Revised History of HIV in Kenya – Part III – Chronology Posted by on August 13, 2014

I mentioned some historical factors in Part II, so I’ve put together a timeline for Kenya’s epidemic, which seems appropriate in a history, especially a quick and dirty one. Some of the factors involved in HIV epidemic spread date back to the beginning of the century (or the beginning of humanity in the case of population). The table only lists some factors that have played, or are said to have played, a significant role; others will crop up later.

HIV Timeline Kenya

[Click on image to expand]

These factors would not have made it in any way inevitable that HIV would spread rapidly in certain places, more slowly in others and hardly at all in a few. That’s not what I’m arguing here. But there is an exception, a factor which doesn’t yet appear in the above table. Unsafe healthcare facilities to which the majority of a population has access render outbreaks of certain diseases more likely, and probably facilitate the exponential growth of some of those diseases more efficiently than any other factor possibly could. This is not true for HIV alone (or even MRSA in wealthy countries). TB can spread in health facilities (though deep mines are likely to be far more notorious in this instance), as seen in the case of Tugela Ferry in South Africa. Hepatitis C (and B) has often been spread widely through public health programs, such as in Egypt. Ebola is also very easily spread this way, and early accounts from some outbreaks are fairly explicit about this. Many of the people infected in the current outbreak are healthcare personnel. Many more were likely to have been infected by contact with other infected people in health facilities, perhaps even through contact with doctors and nurses (either because the doctors or nurses were infected or because their protective clothing was contaminated). Unsafe healthcare, as mentioned in Part II, is said to have ‘kickstarted’ the HIV epidemic. But conditions in healthcare facilities in African hospitals are appalling, so unsafe that the UN warns its employees not to use them. Tourists are warned to avoid injections and other procedures, even to carry their own injecting equipment. It’s only Africans themselves who are urged to go to health facilities and public health programs, without any warnings about unsafe practices or risks.

What is inevitable is that, if there is ever an outbreak of a disease that can be spread through unsafe healthcare, it will result in a serious epidemic in countries where conditions in healthcare facilities are unsafe. Such outbreaks have been documented in the case of HIV in Libya, Kazakhstan, Kyrgyzstan, Romania and other countries. But the possibility of such outbreaks in sub-Saharan African health facilities has not been investigated. Or, if such an occurrence has been investigated, the findings have never been published.

So there were political, economic, environmental, ecological, demographic and various other factors in play long before HIV first reached Kenya, said to be some time in the 1950s. They are briefly mentioned in the above table because they need to be explained, which requires some historical detail (more than a superficial account is beyond the scope of this post). Therefore, I shall jump to the end of the colonial period right now and address remaining issues another time.

The first 10 or 15 years of independence saw a lot of progress in Kenya, especially in education and healthcare. Spending increased to provide these and other services for everyone, rather than the select few who would have had access to them before independence. The relative prosperity of this period was short lived. Global and more local economic and political events in the 1970s and 1980s would have already begun to interrupt progress. But the need to accept loans from the World Bank and the IMF, which had strict ‘austerity’ conditions attached to them, spelled the end of improved access to health and education, cuts in all public spending, wage freezes, spiraling unemployment and a severely reduced public sector, including health and education, which are among the biggest employers.

In 1978 Moi took over from Kenyatta, the first president after independence, and was happy to comply with the stringent conditions demanded by these international financial institutions through their structural adjustment policies, as long as it meant he could get his hands on a lot of money. He remained president for 26 years, during which time the population went from 16 million to about double that figure, while health, education, infrastructure and other sectors were held, nominally, at around 1980s levels, although these sectors declined rapidly during the Moi regime.

This is where the story becomes surprising (if you think it’s all about sex). HIV had been around for a few decades, albeit unnoticed. But it spread rapidly from some time in the 80s and prevalence probably peaked in the late 90s, at 10 or 11%. Very high death rates, peaking in the early to mid 2000s, helped ensure that prevalence was halved by 2012 or 2013, according to the latest figures (although that’s 5% of a population that is increasing at over 2.5% per annum). But why would HIV prevalence decline when the worst effects of structural adjustment policies were being felt, from early in the 1990s onward, as it appears from my (admittedly rough) chronology? The annual rate of new infections, incidence, is said to have peaked in the early 90s, which would account for a peak in prevalence a few years later, and a subsequent drop. But we associate increased levels of spending on health, education, infrastructure and the like on development, better education, and better levels of health. How could the epidemic appear to be receding at precisely this time? The country had done nothing to deserve improvement in any area of health, let alone HIV, which Moi refused to acknowledge for most of his term of office.

When I wrote the brief account of HIV in Kenya five years ago, I was still busy questioning some of the completely unexpected findings I had uncovered for my dissertation, most or all of which the HIV industry was already aware. Why were wealthier people often more likely to be infected? Why were urban dwelling people also more likely? Why were ‘unsafe’ sexual behaviors often little more associated with HIV transmission than an absence of such behaviors, or the presence of ‘safe’ sexual behaviors? In Kenya, almost all development indicators were at their lowest in the Northeastern province, but HIV prevalence was also lowest there. Condom use was minimal, fertility rates were high even for Kenya, gender inequality was high, polygamy was common, as was female genital mutilation, intergenerational sex and marriage (large differences in age between partners, usually older men and younger women) were far more common than anywhere else in the country, and many people had little knowledge of HIV.

The list continues. Population was growing rapidly in some of these areas, several were undergoing urbanization (or something similar) and population density was increasing in others. Shortly after I started studying HIV it was clear to me that it couldn’t possibly be all about heterosexual behavior, I just didn’t know what could account for very high prevalence figures in some places and low figures in others. Upon visiting Kenya in 2002, when everyone told me about ‘traditional’ practices and all manner of factors that resulted in high rates of HIV transmission, they were also talking about how ‘abstaining’ (a word I associated with religion), ‘faithfulness’ (a word I associated with courtly love) and ‘condomizing’, a word I didn’t associate with anything at all, were resulting in declining prevalence figures. How could this be, and weren’t high death rates already explaining these drops in prevalence?

Obliged to exclude certain modes of HIV transmission from my dissertation to keep it focused and within size restrictions, I was advised to lose sections on non-sexual HIV transmission. It took me a about a year to get back to that, but when I did, all the previously unexpected findings started to make sense: I was sure that HIV wasn’t solely transmitted through sex, I just didn’t know that the HIV industry had been so strenuously denying the proportion that unsafe healthcare, cosmetic and traditional practices had been contributing in the past, and were still, obviously, contributing. It became clear that the industry somehow resembled an old boy network infused with a kind of freemasonry, a fair amount of evangelical zeal, and a good helping of neo-eugenicism acquired from some of the big NGOs that got in on the HIV act early on.

HIV is transmitted through heterosexual sex, that’s not in question. But people in Northeastern province don’t have much access to healthcare, infrastructure, education or many other benefits, and that is what may have protected people living in that province from HIV. In contrast, people living close to better developed infrastructures, people in cities (especially Nairobi, Mombasa and Kisumu), wealthier people and people living closest to health facilities may have, where conditions in health facilities were not adequate, faced very high risks. They are not ‘at risk’ populations, so much as ‘populations put at risk’ by the institutions that persuade them to avail of their services but can’t always provide these services safely. There are, indeed, certain behaviors that increase the risk of being infected with HIV, but they are not all sexual behaviors, they are not all individual behaviors and they are not all the behaviors of poor, uneducated, powerless people, either.

It’s not that health, education and infrastructure are not benefits, they are. Kenyans and people of all underdeveloped countries need more healthcare, more education and more (appropriate) infrastructure, lots more than they have ever had. But unsafe healthcare can be a lot worse than no healthcare. When structural adjustment policies reduced access to the benefits of health, education and others, they may also have reduced the exposure of most people in Kenya to an important, but rarely discussed, HIV risk.

An estimated 1.6 million people are living with HIV today, but that’s a relatively small percentage of the population. HIV prevalence in countries with far better and more equitable access to health facilities, such as Botswana, is among the highest three in the world. The HIV region where the epidemic is said to have begun, with relatively poor infrastructure, also has a far less serious epidemic than the southern region. Where road networks are almost entirely absent, such as in the Northeastern province of Kenya (and some countries in low prevalence North Africa), there are few health facilities, and access to these facilities is low. But along Kenya’s best road networks (which are certainly nothing to boast about) HIV prevalence is higher. The best health facilities are not found in isolated areas, of course. But nor are the best health facilities likely to have been safe places in the 1980s and 1990s. Some of them are still unsafe, we just don’t know how unsafe, and exactly what proportion of HIV is transmitted through unsafe healthcare.

Infrastructure alone didn’t result in rapid transmission of HIV, much of that was built during the colonial period. Nor did the existence of health facilities, or even public health programs, guarantee that a HIV epidemic would be severe. But increased access to health facilities where safety standards sometimes (often?) fell below par might explain the huge increases in HIV prevalence that occurred inside very short periods. People outside of the HIV industry would wonder how a virus that is difficult to transmit through heterosexual sex could appear ti occur in ‘explosive’ outbreaks, with prevalence doubling in less than a year. The industry would assure them that ‘Africans’ clearly engage in levels of unsafe sex that is beyond what any non-Africans could manage. Those whose prejudices already matched those of the HIV institutions accepted this explanation. Anyone who continued to question such a racist view of HIV was accused of denialism and shunned by their professional colleagues (unless they didn’t have any professional colleagues, or a profession).

Much of the evidence collected over the last 30 years, even evidence collected by the HIV industry itself, points to a rule of thumb: you can not work out levels of sexual behavior from HIV prevalence; and you can not work out HIV prevalence from levels of sexual behavior. But the HIV industry, outrageously, insist that high HIV prevalence in African countries is evidence for high rates of ‘unsafe’ sexual behavior, and  that high rates of sexual behavior ‘explain’ or predict high rates of transmission.

When I turned my attention to non-sexual HIV transmission I came by a small group of people who are still questioning the orthodoxy, as they had been doing for many years. Some have retired, others don’t depend on HIV related funding for their work, most are doing it for free. There are those who had been involved in HIV related work, and they are either ignored or treated with contempt for even talking about unsafe healthcare, or anything else that makes the sexual behavior paradigm look like the institutional racism that it is. The mere mention of some names involved can end a conversation, or elicit  no more than a peremptory gesture, which is the only evidence the HIV industry has yet been able to muster against the possibility that non-sexual modes of transmission may make a significant contribution to the most severe HIV epidemics in Africa.

In Kenya, people will still tell you about how much ‘Africans’ love sex. If you ask why prevalence in Homa Bay, bordering on Lake Victoria, is 135 times higher than it is in Wajir, not far from the border with Somalia (though not very close to anything else worth speaking of), they will say that people around Lake Victoria love sex. Beyond that, they have no credible explanation. Every now and again there’s a flurry of activity around some issue that attracts the media’s attention and this can crop up in conversations. For example, in 2002 some people were still talking about ‘devil worship’, for which a well publicized commission was set up, and which never published the results of its inquiries. But HIV stories drowned out even stories as titillating as devil worship. People around Lake Victoria will tell you with great relish about the sexual behaviors of fishermen, ‘barmaids’, transport personnel, Ugandans, Luos (the predominant tribe around Lake Victoria) and various other groups that have at various times been held up for scrutiny by the HIV industry and, as a result, thoroughly stigmatized.

HIV has been in Kenya since just after the middle of the 20th century and it was recognized from the early 1980s. It has spread around the country, though very unevenly, perhaps over a period of 40 years. The HIV industry has convinced Kenyans that it is individual sexual behavior that ‘spreads’ HIV. But transmission rates declined before any effort was made to address the epidemic, something the HIV industry are unable to explain. So the epidemic is still very much alive, and unexplained by the orthodox story. Kenyans still don’t know what is driving the epidemic, therefore they don’t know how to prevent it from continuing.

There’s more, a lot more. Hopefully I’ll have time soon.

AIDS, blood, circumcision, ebola, HIV, iatrogenic, MGM, nosocomial, VMMC , , , , , , , , , , , , , , , , , , ,

South Africa: Don’t Panic About Ebola, We Have Extremely Effective Surveillance Systems

Comments Off on South Africa: Don’t Panic About Ebola, We Have Extremely Effective Surveillance Systems Posted by on July 31, 2014

Some may beg to differ with the health minister. While TB is very different from ebola, South Africans will (I hope) recall hearing about an epidemic of multidrug-resistant (MDR) and extensively drug resistant (XDR) TB being transmitted in health facilities in South Africa and surrounding countries, perhaps since the early 2000s. Scaremongering about infectious disease outbreaks doesn’t do anyone any good, but nor does underestimating the ease with which diseases can spread, within a country and internationally.

A three decade HIV pandemic has shown us that surveillance systems on their own are not enough. The XDR/MDR epidemic is very closely connected with the HIV epidemic in South Africa and has been attributed to poor infection control. Countries that wish to control disease spread need strong health systems. However, the reaction to HIV has not been a sustained strengthening of health systems as a whole, but rather a vertical, cherry-picking approach. The result is that most countries in sub-Saharan Africa now have crumbling health systems, massive shortages in skilled health personnel, inadequate equipment and unreliable vital supplies.

Conditions are so dangerous that UNAIDS advises UN personnel not to use health facilities in developing countries, although the institution seems to believe that the same facilities are fine for Africans. Guinea, Liberia and Sierra Leone have relatively low HIV prevalence, whereas the number of HIV positive people in Nigeria could be the second highest in the world; South Africa is home to the highest population of HIV positive people. This has only weakened health systems further.

Nor is there any need to single out South Africa, Nigeria or the three countries that have the worst ebola outbreaks so far. There are Service Provision Assessments and other reports for many African countries showing that basic supplies such as gloves, soap and water, drugs, even injecting and other equipment, are frequently lacking. There are also scores of articles alluding to dangerous conditions, some published many years ago.

The South African health minister, and health ministers in all African countries, would be better off using outbreaks of ebola, MDR and XDR TB, hepatitis and HIV as arguments for investing in health systems that can provide safe health services for everyone, rather than for the rich alone, or for those suffering from headline grabbing diseases. Nosocomial TB in South Africa is thought to have started more than ten years ago, and affects many health facilities, in several countries. Therefore, there have been numerous outbreaks over that period, not just a few isolated instances.

Many of the people who have died of ebola are health professionals and others who are probably more aware of the risks they face than their patients are. Claiming that health systems are fine and that they are able to cope is a betrayal of the work their health professionals are doing. Minister Dr Aaron Motsoaledi should tell the WHO and other international institutions something that is an open secret about healthcare safety in African countries – it is in very urgent need of attention.

AIDS, blood, circumcision, ebola, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

Comments Off on Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics Posted by on July 30, 2014

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else’s blood, or how to avoid this.

The Don’t Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else’s blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don’t Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don’t know there is a risk and they don’t know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO’s ‘Tool C’, also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

“Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface…

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub…

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections…

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle…

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes…

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container.”

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and ‘traditional’ practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.

AIDS, blood, circumcision, ebola, female genital mutilation, FGM, HIV, iatrogenic, male genital mutilation, mass male circumcision, MGM, nosocomial, VMMC

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