Bloodborne HIV: Don't Get Stuck!

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Hepatitis B Virus and Kenya’s Mass Male Circumcision Programs – Why the Secrecy?

With all the posturing in the recently released Kenya Aids Indicator Survey (2012) about mass male circumcision, whether performed in completely unsterile conditions found in traditional settings or the (hopefully) more sterile settings of health facilities, nothing was mentioned about hepatitis B or C. But an article in the East African describes a piece of research carried out by the Kenya Medical Research Institute into hepatitis B (HBV) which finds that prevalence is increasing.

Amazingly, the article admits that the “modes of transmission [for HBV] are similar to HIV — sexual transmission, contaminated blood products and mother to child transmission”; it is “passed from person to person through bodily fluids such as blood, semen or vaginal fluids”. Following a recent paper on HIV transmission through medical injections, it is very important to stress that HIV, like HBV, can be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

The article is equally frank about the lack of research into HBV in Kenya: “scientists say the reason for the rise in HBV in Kenya is still unknown since no scientific study has been done to explain the phenomenon”. In contrast, the HIV industry is a lot less frank about non-sexual HIV transmission, even though the country’s Infection Control Policy admits that “Epidemiological data on HAIs [Healthcare Associated Infection] in Kenya is currently lacking, but the risk for HAIs is high”. Slowly, some of these glaring gaps in research are being filled in, though the HIV industry displays a confidence that seems entirely unjustified.

Importantly, HBV among blood donors in Kenya is rising. Are those donating their blood being exposed to contaminated medical instruments through the blood transfusion services? The Kenyan Blood Transfusion Service is not able to supply enough blood to keep up with current demand, so they would need to make sure that people who donate are not being put at risk of infection with HBV or other blood borne viruses. While no one would want to scare people away from health facilities or from blood donation, keeping risks a secret would surely be a lot worse, wouldn’t it?

The article suggests that the counties finding high rates of HBV are in the Northern parts of Kenya (which often have the lowest HIV rates). It is suggested that “The likely causes of HBV in the region are cultural practices like tattooing, circumcising without using sterilised implements and because the regions are dry and people may not be able to get proper nutrition that ensures strong immunity.” As usual, there is a reluctance to ask if health facilities might also be somewhat responsible; does that mean these facilities will not be investigated, and that conditions, if unsafe, will not be improved?

There are various hepatitis related campaigns, but are WHO and other international health institutions going to ensure that all the people involved in the country’s mass male circumcision programs, will be protected from infection with HBV and hepatitis C virus (HCV) as well? WHO makes vague claims about huge proportions of HBV and HCV being transmitted as a result of unsafe healthcare. But what exactly are the figures for ‘priority’ mass male circumcision countries? Again, it’s likely that healthcare safety is more of a risk in these ‘priority’ countries, some of the poorest countries, with amongst the lowest levels of healthcare spending in the world, than it is in Western countries; why are we only given one, generalized figure, when the viruses must be much more prevalent in some countries than others?

Egypt, as (just one) example of a country with a serious hepatitis problem, has seen the figure for years of life lost (YLL) through HBV increase by 3,930% in the 20 years from 1990 to 2010. Liver cancer has increased by 361% in the same period. Cirrhosis has increased by 40% to become the number three cause of YLL, accounting for 1,127,000 YLLs, or 7.1% of all YLLs. Whether the almost 100% prevalence of circumcision in the country contributes to these figures is another question, but it shows what can happen in a country where there is a very high level of access to healthcare, yet where healthcare safety is not adequately addressed. One of the main reasons HCV prevalence is higher in Egypt than anywhere else in the world is because of schistosomiasis vaccination programs, which were carried out using inadequately sterilized glass syringes.

Reusable syringes and needles are no longer commonly used, but the WHO data shows that there is still a problem with unsafe injection practices. So the last thing high HIV prevalence African countries need is a vastly increased risk of bloodborne virus transmission through unsafe healthcare, whether this involves reuse of injecting equipment or other items that are used to pierce the skin during healthcare procedures. Mass male circumcision programs will likely increase the incidence of unsafe healthcare practices, including injections, and the WHO’s claimed benefits in terms of averted infections may not be enough to outweigh the risks involved.

Even if levels of protection against sexually transmitted HIV outweigh the risks, and this is highly debatable (and debated, outside of the HIV industry), what about the risks of infection with HBV, HCV or other bloodborne pathogens, including HIV, during the circumcision procedure itself? Some recent research has questioned the safety of Kenya’s health facilities. There are clearly more risks than those pushing the circumcision programs would like to admit; so will those who succumb to HIV industry pressure be advised of those risks? I suspect they will not.

HIV Eradication May Require Regime Change in HIV Industry

Having collected the data in 2012, the Kenya Aids Indicator Survey (KAIS) was released last week. Prevalence has fallen in most provinces. The exceptions are Northeastern Province, where data was not collected due to civil unrest, and Nyanza, where prevalence has increased from almost 14% in 2008 to 15% in 2012. 37% of Kenya’s HIV positive people reside in Nyanza. So the news is not so bad if you don’t come from Nyanza, especially if you don’t come from any of the exceptionally high prevalence towns on the shores of Lake Victoria.

Prevalence is now 5.6%, closer to Tanzania’s 5.1% than Uganda’s 7.2%. As usual, HIV prevalence is generally higher among women (6.9%) than among men (4.4%), higher among urban dwelling people than rural dwelling people and higher among employed people than unemployed people. Prevalence is lowest among females and males who have less education and higher among those who have completed primary or reached secondary or beyond. Prevalence tends to be higher among wealthier quintiles in rural areas and among poorer quintiles in urban areas, which may represent a change in HIV prevalence by wealth quintiles in earlier surveys.

With about 100,000 people being newly infected each year, incidence is said to be 0.5% and the highest number of new infections occurred among people aged between 25 and 34 years, with incidence estimated at 1.2%. Incidence has barely changed between 2007 and 2012, what the report refers to as ‘stable’. The entire epidemic could be described as stable, rather than declining, as prevalence has remained much the same for more than ten years.

Predictably, there are quite a few figures relating to the mass male circumcision program. You don’t put tens of millions of dollars into a program without making sure that you collect data showing that the program was successful. Clearly the program is not successful yet, with the bulk of circumcisions claimed for Nyanza province, which has a prevalence figure nearly three times the national figure. But there is a lot of triumphalist stuff about how high HIV prevalence is among uncircumcised people. Of course, none of the data throws any light on why HIV prevalence is so high among people in this province, so high among Luo people especially, yet not among Kisii or Kuria people.

The level of bullying and manipulation by those running mass male circumcision programs (which the HIV industry likes to refer to as voluntary medical male circumcision or VMMC) becomes apparent when you read some of the literature. Although the invasive operation’s claimed protective value against HIV (and goodness knows what else) has never been very convincing, people are systematically browbeaten over a period of years about hygiene benefits, which have never been demonstrated at all, ‘modernity’ of circumcision, ease of using condoms, increased sexual pleasure and a host of other things for which there is no evidence whatsoever.

According to the abstract “older men should adopt the practice to serve as role models to younger men”, as if there is some moral value in circumcision being provided by a benevolent dictator. UNAIDS addsn a commonly heard claim about “queues of young men and boys awaiting” mass male circumcision, which is clearly drawn from publicity materials rather than from any kind of independent research.

Talking of invasive operations, there is a chapter on blood and injection safety, ironically appearing straight after the mass male circumcision chapter. The figures for blood safety do not sound very encouraging, especially remarks about ‘misclassifications’ in donor records. UNAIDS’ ‘all men are bastards, all women are victims’ theory of HIV transmission gets a bit of a knock as well since nearly four times as many men as women said they donated blood in the 12 months before the survey. The findings about injection safety have been mentioned already on this site  when a full paper was published on the subject in May.

The question now is ‘what next’? Mounds of data have been collected over many years, mostly high level data that gives few clues about how people are becoming infected. Data about ‘attitudes’, sexual behavior, economic circumstances, education, etc, have not allowed any useful ‘targeting’ because the usual conclusion is that ‘it is all about sex’ and other kinds of victim blaming. So it’s heartening to hear that data is being collected about blood and injection safety, albeit a very small amount.

The next step needs to involve comprehensive contact tracing, finding out about people’s non-sexual as well as their sexual contacts, visits to health facilities, traditional practitioners, cosmetic providers and anywhere skin-piercing procedures are carried out. If someone is HIV positive it must be asked who, or what did they come into contact with, whether as a result of sexual or any other kind of behavior. Will the deep prejudices of the HIV industry allow them to take these investigations where they need to go, or will the eradication of HIV have to wait until there’s a regime change in the HIV industry?