Bloodborne HIV: Don't Get Stuck!

Medical waste is a serious threat in all developing countries, although it may not be as big a threat as reused contaminated equipment and other unsafe practices in health facilities. Thousands of people scrape a living from dumping sites by trawling for things that can be sold or reused. But if healthcare waste is not being dumped properly, they can come into contact with scalpels, needles, syringes, glass and other items.

The article above mentions the unlicenced clinics that are so common around all slums in Nairobi. But there is no mention of reuse of medical instruments. Perhaps it never happens, but even in legitimate health facilities, some healthcare workers seem to assume that safety precautions are to protect them from accidential exposure to pathogens, not their patients.

I’ve been to several health facilities in Kenya, Tanzania and Uganda and it is fairly obvious that some of the waste never makes it to dumps. It is not unusual to find used equipment on grassy areas, in bushes and in various places on the hospital grounds. I’ve even seen kids playing with clinical waste.

According to the article, backstreet clinics in Nairobi alone are being closed down at a rate of more than 15 a month. I’d be curious to get an idea of what kind of conditions are found in such clinics but I haven’t seen any reports. While those sifting through rubbish face some risk, patients may face even higher risk of illegal clinics are unaware of or not compliant with infection control procedures.

The article cites an estimate from the British Health Protection Agency that up to 1 in 300 people could be infected with HIV through contact with contaminated medical waste. But if that’s the case in the UK, where HIV prevalence is very low, the risk must be far higher in Nairobi, where prevalence is nearly the highest in the country. The risk of hepatitis and other blood borne diseases is even higher still.

If reports of conditions in Kenyan hospitals are true, unhygienic conditions in dump sites must be the least of their worries when it comes to accidental infection with HIV and other blood borne diseases.

Further to a recent report that parents of 23 thalassemic children who were thought to have been infected with HIV through contaminated blood transfusions were calling for an investigation, it appears their demands are being met, at least in part.

There will be an investigation to, in effect, establish who to blame for the outbreak. The families have a right to expect compensation, but how about recognition that healthcare associated transmission of HIV (and other diseases) can and does occur? How about an investigation to establish how often such incidents occur elsewhere, or how often they might occur in the future? Don’t we want to prevent HIV?

Once the issue becomes top-heavy with lawyers, they are the only ones who will benefit to any great extent. But it is possible that many people are vulnerable to infection with HIV, hepatitis and other diseases through unsafe healthcare, and indeed, unsafe cosmetic procedures. It’s not just children who are at risk, everyone who receives any kind of skin-piercing treatment, whether medical or otherwise, is at risk.

A reminder that unsafe healthcare is not the only possible source of HIV and other diseases comes from an Australian, who is suspected of having been infected after getting a tattoo in Bali. It’s not surprising that it takes one Westerner to become infected for an entire mode of transmission to be investigated, but this is the kind of warning that should have been heard in the run up to the World Cup in South Africa. Instead, there was little published but the usual fatuous rubbish about sex.

HIV experts are well aware that conditions in non-Western countries can be dangerous and that HIV can be transmitted in healthcare and cosmetic facilities: “While tattooists in Western Australian must comply with strict regulations and a code of practice, tattoo parlours overseas may not meet the same standards.” It’s just rare to read about exactly what this means for Westerners. But if Westerners are at risk, so are non-Westerners.

That may come as a surprise to UNAIDS, who are fond of warning their own employees and, at the same time, denying that non-sexual HIV transmission plays a significant role in African epidemics. Worse still, they don’t feel any attention should be given to non-sexual transmission, with the result that people are pretty confused about sexual transmission and totally in the dark about non-sexual transmission.

If I haven’t made it clear before, I think UNAIDS is an expensive waste of money that could be spent on health and development in general, rather than supporting the sexual fantasies of a bunch of overpaid and ineffective bureaucrats.

A woman in the Indian state of Andhra Pradesh is thought to have been infected with HIV from a contaminated blood transfusion. The blood was purchased from the Red Cross blood bank. The woman had received several negative blood tests before the delivery so it is unlikely she was infected by her partner. The article doesn’t say whether her partner was tested.

While the risk of being infected through medical procedures may be low in India, where HIV prevalence is lower than it is in the US, the risk in Uganda and other African countries is a lot higher. Most Eastern and Southern African countries have HIV prevalence levels many times higher than those found in India.

Therefore, it’s surprising that health services in Uganda are being advised to continue using the injectible version of Depo Provera, despite evidence that it could be involved in higher transmission rates. Even if the hormone involved is not responsible for higher transmission rates, this does not rule out the possibility that unsafe injections are at least partly involved.

The article goes on about other worries, such as low contraceptive use, but this misses the issue of unsafe healthcare. In the long run, contraceptive use is not going to increase if the whole process of birth control becomes controversial. Rather than simply telling health services to continue using injectible Depo Provera, might it not be more reassuring to investigate safety conditions in health facilities?

The contraception agenda seems to be driven by outside interests, rather than by African countries. There may well be an ‘unmet need’ for contraception, but no one in their right mind would opt for a contraceptive method that carries risks of infection with HIV, or that increases the risk of transmitting HIV.

If those driving the contraception agenda wish to increase access to various birth control methods, they also need to be able to reassure people as to the safety of those methods. And that means the safety of the method of administration, not just the safety of the substance administered. The WHO may well wish to wait until their ‘high level meeting’ in January, but safety in health facilities should not have to wait.

In fact, we should not still be avoiding questions about HIV transmission in health facilities. Even if there were no evidence of healthcare associated infection or transmission, and that is far from the case, health facilities should be routinely inspected; they should always be able to account for their safety provisions. Right now, they are not able to do so.

If WHO and others don’t wish to address the safety or otherwise of Depo Provera, that’s bad enough. But the issue of patient safety in health facilities is far too urgent and far too long ignored to be treated in the same doctrinaire manner. HIV has been found to have been transmitted in many countries, rich and poor, in health facilities. The threat of nosocomial and iatrogenic transmission of HIV in African countries can not be dismissed any longer. As in the Indian case above, investigation is needed, not a continuation of summary dismissal of the evidence by international health institutions.

Guarding against transmission of HIV through blood transfusions has been found to ‘offer high returns’, which will be comforting for those who face especially high risk from such incidents. Blood transfusions are by no means the only route to HIV infection in health facilities, but the probability of transmission is very high; if someone receives a transfusion of HIV contaminated blood, they will almost certainly be infected.

However, while the probability of transmission is far lower for reused syringes, needles, intravenous drip equipment, etc, people are many times more likely to experience these procedures, often many times in their lives. In other words, these procedures may carry a low probability of transmission where the equipment is contaminated, but they happen so frequently that they could represent a significant risk to populations in countries where health facilities are in poor condition, as they are in many African countries.

The above article from the Financial Times mentions some countries, such as Angola, Niger and Tanzania, where “less than a third of donated blood is tested for HIV contamination in a quality-assured manner.” In fact, up to 90% of transfused blood given to pediatric patients may not receive adequate testing, according to research in Tanzania. The WHO even admits that “there is no reliable information on the extent of transfusion-linked infections”, which makes you wonder how commentators can claim that this risk is very small, especially in African countries such as Kenya, Uganda and Tanzania.

But the most interesting revelation is from Paul de Lay of UNAIDS, who says “if he were to have an accident near a rural hospital in some parts of Africa, he would seek a saline drip or other measures to defer the need for transfusion at least until arrival in a better resourced urban medical centre with greater chance of more effectively screened blood”.

There is some advice for Mr de Lay, which comes straight from his esteemed employer: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission.” They go on to say “We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN-approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere [my emphasis]. It is always a good idea to avoid direct exposure to another person’s blood—to avoid not only HIV but also hepatitis and other bloodborne infections.”

In other words, de Lay should refuse all medical attention where other people’s blood may be involved, if possible. But what about people who are not fortunate enough to work in the UN system? Are they not entitled to a warning, at least, concerning what UNAIDS calls the “most efficient means of HIV transmission”?

It’s hard to understand UNAIDS’ policy of exaggerating the relative contribution of sexual transmission and dismissing the relative contribution of non-sexual transmission, despite there clearly being a dearth of research into this area. Catherine Hankins, also of UNAIDS, seems to suggest that warning people about health care associated risks could result in them ignoring sexual risks and, at the same time, avoiding health facilities.

But is it true that people can not mentally process the two kinds of risk? Can we really not tell people in the countries with the worst HIV epidemics in the world that they face both sexual and non-sexual risks? That appears to be UNAIDS’ stance. Are we in the West not warned about intravenous drug use, tattoo parlors and health facilities in high HIV prevalence countries as risks for infection with HIV?

Maybe UNAIDS worry about ‘complacency’ regarding sexual risks is right; after all, the obsession with sex seems to have resulted in complacency regarding non-sexual risks, such as blood transfusions, other unsafe medical practices and even cosmetic and traditional practices that involve skin piercing. But that is no reason for claiming that 80-90% of HIV transmission in African countries is a result of heterosexual sex when we have little idea of what the relative contribution of non-sexual exposures is. People need to be warned about non-sexual HIV exposure; if it poses a risk to UN employees working in African countries, it poses a risk to all Africans.

An estimated 41 children were infected with HIV in hospitals in Osh province, Kyrgyzstan in a single outbreak in 2007. Mothers are still trying to get the government to pay compensation after an investigation found that the infections were a result of negligence. The women are also demanding further investigations in case there were other undiscovered infections, in Osh province or elsewhere. Another 200 hospital transmitted infections have already been identified throughout the country and 17 new cases have been identified this year alone.

Unfortunately they are also demanding punishment for the health personnel involved. Of course, health professionals must behave professionally, and they should face the consequences when they are negligent.

But HIV prevalence in Kyrgyzstan is low, at about 0.1%. Where prevalence is high and conditions in health facilities are poor there could be a lot of similar outbreaks. However, in countries where skilled health personnel are scarce, systematic punishment of those found not to be complying with infection control procedures might have a lot of highly undesirable consequences. Many countries may even lack written procedures, training in their application or supplies required to do so adequately.

The children were infected as a result of receiving contaminated blood transfusions. In countries like Tanzania, up to 90% of transfused blood comes directly from family members and other donors, without going through the blood transfusion service. It is tested for HIV and syphilis once, but the risk of contaminated blood being passed in such conditions is very high. The blood is not tested for hepatitis.

In Kyrgyzstan, a sizable percentage of HIV transmission has been shown to result from unsafe healthcare. In Tanzania, where HIV prevalence is about 60 times higher, no such investigation has ever been carried out. Rather than carrying out such an investigation, UNAIDS estimates that the relative contribution of unsafe healthcare to be 1-2.5%, several times lower than the figure for Kyrgyzstan would suggest. And Tanzania has far lower standards of healthcare, as well.

Many Tanzanians and other East Africans may be protected from hospital transmitted HIV because access to health facilities is relatively low. However, you don’t improve the quality of health services by ensuring that as few people as possible receive healthcare. So, if UNAIDS want more people to avail of health services, including HIV related services, they should first check that health facilities are not risking transmitting HIV and other diseases.

One of the things that prompted my recent post about Implanon birth control implant was a remark in Wikipedia, which links to an article about an alert relating to the product in the UK. Hundreds of women became pregnant while using the product, which is bad enough when the point is to avoid pregnancy.

But if you’re in a country where the safety of health facilities cannot be guaranteed (according to UNAIDS), you might have far greater cause to worry about improper insertion, or any kind of insertion at all, if it involved possible contact with contaminated medical equipment.

The Reuters press release points out that a relatively small number of women became pregnant, but what about the worry that the implant might take place in health facilities with insufficient equipment and supplies, hardly any trained personnel and lax infection control procedures (if any)? After all, another 1,607 women complained of “adverse reactions such as scarring and other problems”.

In the UK, Implanon has been replaced by Nexplanon, but it seems Pathfinder will not be using that and Implanon has not been taken off the market. It will continue to be administered until stocks run out, apparently. So that’s OK, then.

Pathfinder International are intending to scale up the use of Implanon in Ethiopia. This is a hormonal contraceptive implant, inserted under the skin. I hope some care is taken to avoid accidental transmission of blood borne infections, such as hepatitis, HIV and various bactrial conditions.

My attention has been drawn to the 2005 Demographic and Health Survey for Ethiopia, which shows that HIV prevalence is particularly high among women who received care from a health professional during delivery in the past three years, at 9.9%, compared to national prevalence of less than 1.5%. In contrast, HIV prevalence among those who gave birth without care from a health professional was only 1.2%.

There are similarly worrying contrasts for ante-natal care (ANC), with 3.5% prevalence among those who receive ANC by a health professional, compared to only 1% among those who did not.

In common with all high HIV prevalence African countries, HIV prevalence is higher among women than men. It is also many times higher in urban areas, compared to rural areas. And it is higher among the wealthy than it is among the poor.

These figures, and others in a more recent Preliminary Demographic and Health Survey for Ethiopia, suggest that HIV is very unlikely to be transmitted sexually. This raises the question of how it is being transmitted. Could wealthier, city dwelling people, with better access to health professionals face higher risks than poorer, rural dwelling people, who may never see a health professional face to face? Contraceptive use is also far higher in urban than rural areas.

Pathfinder use the popular buzzword, ‘task-shifting’, to reassure us that there may be few health professionals in the country, but some kind of training can be given to those there are, even to those who are not health professionals but are doing work that should be done by professionals. The term ‘task-shifting’ is a bit like ‘coping mechanisms’ and ‘extended families’, which allow us to believe that they’ll be ok, after all, they are Africans.

It is to be hoped that use of Implanon and other invasive family planning methods that involve breaking of the skin are carried out in sterile conditions by people who know the risks and are taking the necessary precautions to avoid them.

It would also be good to think this campaign involves informing Ethiopians about non-sexual risks of HIV transmission, such as those faced by those using certain forms of birth control, such as Implanon and other implants. Implants need to be removed in sterile conditions, as well as inserted in sterile conditions.

The Rebecca Project has published a policy brief on non-consensual research in African countries, invoking the US town of Tuskegee in the title, where non-consensual research into syphilis saw many African Americans being infected with the disease and passing it on to their children and partners as a known (to the researchers) consequence of the program. Similar work was carried out in Guatemala, for which the US government has recently ‘apologised’.

Much of the research currently being carried out in African countries by US companies and US funded institutions is unethical and illegal. It results in innocent people being infected with diseases and affected by side-effects in ways that would be entirely unacceptable in Western countries, even in the US. Often, the people abused by these researchers are led to believe they are receiving routine medical care.

Sometimes informed consent is sought; sometimes it is given. But there is always a question mark over how well informed people can be when they may only have primary education or less, and education of very low quality, at that. It is in the interest of those recruiting participants to supply the numbers required, so the less participants know, the better for the researchers.

The Rebecca Project wishes to see these practices investigated and discussed at congressional hearings. They hope that this will lead to reforms in the institutions involved so that such abuses no longer occur, the protection of victims and the punishment of the perpetrators for these crimes against humanity.

David Gisselquist of Don’t Get Stuck With HIV has also written a comprehensive review of the literature showing massive levels of such unethical and illegal research, involving many tens of thousands of Africans. It would be impossible now to reverse the damage that has been done, for various reasons, including lack of care taken to record and report vital information on the victims. (A copy of Gisselquist’s review can be downloaded from the DGS site.) But these practices must stop.

Both the Rebecca Project brief and Gisselquist’s review bring home the fact that there are many people involved in carrying out these activities, scientists, policy experts, politicians and medical personnel, from rich countries as well as from developing countries. Many of the people involved are among the best informed and best educated in the business. If their education in ethical behavior is as seriously lacking as it appears to be, they should not have been involved in the first place.

If experiments on children, intentional or avoidable infection with an incurable and deadly disease, failure to obtain consent or to provide information that could influence consent and other excesses brought to light in these documents involved Jews, Romani people , homosexuals or other groups, instead of Africans, would they have been allowed to take place? And if they took place, would they be allowed to continue, as they are being allowed to in African countries right now?

Rebecca Project documents abuses that took place in a number of countries, as recently as the last few years, carried out by pharmaceutical multinationals, US health institutions, high profile donors such as the Gates and Rockefeller Foundations, international NGOs such as FHI and others. Often present is the notion of ‘population control’, something that is never far from the ideology of the various US parties involved. Reducing population is considered by many of these parties to be a viable development paradigm, although a lot of development theorists might classify it as being of mere historical interest.

Some of the incidents involved the use of the injectible hormonal contrecptive Depo Provera, mentioned on this blog on several occasions. Participants were told they were receiving routine health care. Another involved the use of the HIV drug Tenofovir, which has had quite a short but highly chequered history. They were not informed about the risks involved. Both drugs are still widely used, though questions have long been raised about many of their uses.

The list goes on, some of the drugs and pharmaecutical companies being well known, others not so well promoted in the mainstream press. To be fair, some of those who profited from the work, or who could have done so, raised objections. But they were mostly ignored until a lot of damage had been done. A few million in bribes and a few hundred thousand in ‘compensation’ is nothing to the multi-billion dollar pharmaceutical industry. They have survived many such crises and are likely to survive many more, unlike their victims. For the industry, being forced to address a fraction of the damage they do is only a very small cost, but the profits are massive.

The list of abuses is disgusting, including sterilization of women after getting consent through intimidation, pressure or cash, failing to report deaths and serious injuries and using babies and pregnant women as human subjects. One researcher reported being “unfairly assailed by pedantic saboteurs who could not grasp the necessary difference between U.S. safety standards and the more lenient standards that a country like Uganda deserved.”

Media attention can be way out of proportion when it comes to certain issues, such as some questionable findings about HIV medications or the ‘lack of evidence’ of any danger with using Depo Provera. But these kinds of systematic abuses by academics, political and industrial leaders and other powerful people which the Rebecca Project outline just seem to pass unnoticed by the proponents of ‘public interest’. Perhaps here, public interest is outweighed by financial interest? Or maybe the powerful are ‘us’ and Africans are just ‘them’, when it comes to the mainstream press?

There’s more. But I think the point is clear: there are many double standards involved in research, where all sorts of inhuman procedures can be carried out in African countries but not in the West. And abuses that take place in African countries are systematically covered up, if records are even available to conceal, lies are told, whistleblowers are discredited and public money goes into whatever supports the status quo, and shies away from anything remotely like change for the better.

Westerners’ obsession with population control in developing countries at all costs can be hard to fathom. Tens of millions of aid dollars are spent on Depo Provera and similar hormonal contraceptives, alone, which have long been known to be unsafe. Needless to say, they are mainly used by people in poor countries, especially in African countries.

But the dangers of Depo Provera, which includes HIV transmission from men to women and from women to men, are considered a small price to pay for the satisfaction of the Western mind, which is convinced that if there were fewer people in poor countries, the ones left wouldn’t be so poor; and that the way to achieve this panacea is to push contraceptives of all kinds, safe, unsafe, expensive, cheap, effective and ineffective, on poor people.

So the Reproductive Health Reality Check site argues for the benefits of the copper intrauterine device (IUD), without reference to the wishes of those who may be recipients of Western funded IUD programs. Without reference also to the safety of widespread use of these devices.

What about countries with less than half the health personnel they need, less than half the hospitals and medical supplies? Where many people never see a trained health professional and where many of those who do are more likely to be infected with something incurable at the clinic than in their own homes?

Some become so fervent about population control that they implement female sterilization programs, advocate for them or try to foist them on women, who are promised a great life as a result. Sometimes they are bribed or otherwise coerced into accepting something that is not what they want and may do a lot of harm, medically and socially.

While this may sometimes elicit some sympathy even from those who still think enforced population control is acceptable and effective, they don’t seem so worried about the risks of nosocomial infection with HIV, hepatitis and other diseases that women face when they go to a health facility.

The whole population control theory of development is on shaky ground, anyhow. True, there are many people whose families are too big. But lower birth rates follow developments in health, education and social services, not the other way around. Small families in Tanzania and other African countries are usually from wealthier and better educated families themselves; the family doesn’t become wealthy just because there are few children.

Clinton got a lot of attention by claiming that an AIDS-free generation is now possible. She claims this on the basis of fairly flimsy reasoning. Firstly, the best way of preventing mother to child HIV transmission is to ensure that mothers do not get infected. Blindingly obvious as that may sound, until that is made a priority, there will be no AIDS-free generation.

The facts that HIV can be transmitted sexually and that pregnant women have almost certainly been engaging in unprotected sex does not mean that HIV positive pregnant women, and those who have recently given birth, were necessarily infected sexually. If their sexual partner was also tested, it would be found that many of them are HIV negative. But partners are not routinely tested.

Instead, it is assumed that if a woman is infected with HIV, either her partner infected her or she has other partners, one of whom infected her. The fact that she insists otherwise is not generally taken into consideration. It is implied that African women, the biggest HIV positive group in the world by a long shot, generally lie.

Clinton also grabs at mass male circumcision, another highly questionable HIV prevention intervention. Even some HIV politbureau approved sources have shown that the evidence is not conclusive, that while in a number of countries HIV prevalence appears to be higher among uncircumcised men, in others prevalence is lower. In addition, while male circumcision is said to reduce transmission from females to males, it has also been suggested that it increases transmission from males to females.

The third intervention Clinton mentions, because these things so often come in threes, is scaling up treatment for people living with HIV. She may remember the ‘three by five’ initiative, the aim to get three million people on antiretroviral treatment (ART) by the year 2005? It took longer than expected. And six years later, the figure is still a long way from being doubled, at about five million.

One of the reasons why less than one third of the estimated 15 million people in need of ART receive it is because they are so incredibly expensive. Clinton makes a big thing of mentioning her husband’s foundation, which has orchestrated very well publicized ‘reductions’ in drug prices. But those reductions were from levels unaffordable anywhere to levels unaffordable in the countries where the majority of HIV positive people live.

In fact, countries with high HIV prevalence are not even able to guarantee an adequate supply of drugs to those on treatment, often only 20-25% of those in need. Many countries regularly run out of testing kits and other supplies. And as for anything beyond pharmaceuticals, because they are a profitable business, forget it. People without enough food or clean water are often more likely to to get HIV drugs than any other form of treatment. So they die of all sorts of things, just not headline diseases.

Combining these interventions, even by including many others, will have little impact on the worst epidemics until non-sexual drivers of the virus have been identified, investigated and eliminated. But Clinton made no mention of things like unsafe healthcare or cosmetic services. And why would she? Mention of such matters is not politbureau approved.

Far from ushering in a HIV-free generation, the big players in the HIV industry have been keeping things ticking over nicely for years, and reaping ever-increasing profits. Given Clinton’s remarks (and her husband’s machinations), this is likely to continue for the foreseeable.