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Tag Archives: HCV

Whites Only? Investigations Reveal Hospital Transmitted Hepatitis Infections In US

The satirical site The Onion ran the headline ‘Experts: Ebola Vaccine At Least 50 White People Away‘ at the end of July. I’m not citing this article because I think it is funny, but because it raises a shocking point very succinctly, one that must have passed through the minds of many over the past few months.

If such an outbreak were to become established in a wealthy country, mainly inhabited by white people, would it still be raging 9 months later? And what efforts would be made to establish the source of the infections?

There is probably no wealthy country precedent to compare with the sort of epidemics that are frequently found in poor countries, often without even attracting the notice of the western world (or not for very long). But a recent article published in the Mayo Clinic Proceedings outlines the kind of work that went into investigating the infection of 84 people with hepatitis C (HCV) and another 34 with bacterial infections in US hospitals over a 14 year period. In fact, the paper outlines a whole series of investigations, very impressive work, too.

Six healthcare personnel were identified as a result of these many, lengthy and thorough investigations. That’s an average of almost 20 patients infected for each worker. An estimated 30,000 patients were potentially exposed to blood-borne pathogens by these six people. Twenty three different hospitals were involved, in 10 different states. (Naturally, I don’t really know if the victims were all white people; the authors are far too polite to mention such detail.)

A 2009 article entitled ‘Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review‘, by Savanna Reid, estimates that 20 million medical injections contaminated with blood from a patient with HIV are administered every year in Africa. Other research by Yves Hutin, entitled ‘Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates‘, estimates that out of the 17 billion injections administered every year globally, 7 billion of them are unsafe.

So where are the HIV and hepatitis outbreak investigations carried out in African countries? They are not listed in PubMed, unless they are called something else, to throw investigators off the scent. Such an investigation was carried out in Pakistan in 2008, but as it confirmed the worst fears of those who believe that unsafe healthcare is a serious risk it appears to have attracted very little attention (and turned into what looks like a cover-up).

So what do we know about unsafe healthcare in African countries, in the absence of such investigations? We know that infants with HIV negative mothers were probably infected through unsafe healthcare in Mozambique, and some of the infants may have gone on to infect their mothers (though it hasn’t been seen fit to explain to these mothers how their infants may have been infected, nor even the likely source of their own infection).

We know that people who have received medical injections in Kenya and several other countries are several times more likely to be HIV positive than those who have not. We know that women who have sex only with other women in Namibia and other southern African countries have been infected and that their non-sexual risks have not been investigated. We know that many people found to be infected with HIV in most African countries have said they have not had sex, or that they have not had sex with a HIV positive person, or that they have only engaged in safe sex [earlier version corrected].

In fact, there are numerous instances of HIV outbreaks in African countries, and probably other diseases, which have very likely been caused by unsafe healthcare, reused syringes and other equipment, failure to comply with infection procedures, etc. But none of them have been investigated. Instead, there are vast quantities of data shoved into mathematical ‘models’, showing that HIV is almost always transmitted through heterosexual behavior in African countries (this being just one example).

Completely untrue, but in accordance with the ‘promiscuous African’ myth, which has a long history in the medical (and eugenics) literature. The authors of such papers systematically ignore empirical data and fail to investigate outbreaks, they assume that African people themselves are either seriously mistaken about their sexual history or just tell lies, and they go unchallenged by their fellow academics and even peer reviewers, who have the luxury of remaining anonymous, but seemingly prefer to toe the party line.

No doubt these mathematical models are great examples of academic prowess and rigor, that stand up to the highest levels of scrutiny. But they are no substitute for the kind of investigations that have been carried out into what is thought to be a mere tip of the iceberg in hospital transmitted hepatitis and bacterial infections in the US. However brilliant these models are in the field of epidemiology, they are the work of people who care nothing about their fellow human beings in African countries.

Why do these highly qualified academics care so little about poor black people and, apparently, so much about people more likely to be wealthy and white? Is it academic vanity, money, some kind of animalistic competitive instinct, or a combination of these? The challenge to all these clever academics, who can publish their work in the most prestigious journals and be cited in the cream of the western media, is to go to the same lengths investigating and stopping HIV (and ebola, HCV and other diseases) in African countries as they do in parts of the US before the epidemic spreads any further.

Absurd and stigmatizing estimates about how most adults in Malawi get HIV

The WHO and UNAIDS promote their Modes of Transmission model[1] to estimate numbers of HIV infections that adults get from various risks. The model has a simple mistake in its design – causing anyone who uses it to overlook crucial data on HIV in married couples and leading thereby to grossly inflated estimates of numbers of HIV infections acquired from spouses.[2,3]

Several experts recently used WHO’s and UNAIDS’s Modes of Transmission model to identify important risks in Malawi’s HIV epidemic. Their published results[4] provide another illustration of ridiculous, stigmatizing, and anti-family estimates produced by the model. Here’s the gist of what they conclude: Infections from spouses account for 81% of new HIV infections in Malawi (76,688 out of an estimated total of 94,455 infections; see Table).

Simple logic says this is absurd, even without looking at any evidence or data: The number of people getting HIV from their spouses cannot exceed the number of spouses bringing HIV into their families (from any source, such as unsafe health care or non-spousal sex partner). This is logically necessary year-by-year in an epidemic, such as Malawi’s, that has been more or less stable over time. Furthermore, a large percentage of people who are married and HIV-positive die without ever infecting their spouses. So the number of new infections coming from spouses will be much less than half of all new infections.

But that’s not what the model says. Where’s the problem?

The model starts out OK: Using data for 2007, the model finds 2,095,000 married men and 2,497,000 married women (roughly 20% of women were in polygamous marriages).[4] Next, using data from Malawi’s 2004 national Demographic and Health Survey,[5] the model recognizes that more than 10% of married men and women were HIV-positive. So far so good.

But then the model falls off the rails. It assumes that almost all HIV-positive married adults were a risk to infect their spouses. This ignores the well-documented fact that many people who are married and HIV-positive have partners who are also HIV-positive – no one is going to infect anyone in such couples. According to the same 2004 national survey, only 4% of married men in Malawi were at risk to get HIV from their wives (that is, 4% were HIV-negative with an HIV-positive wife), and only 5.7% of married women were at risk to get HIV from their husbands.

Table 1: Estimated number of HIV infections acquired from spouses

Model, risk category for married adults Number of married men Number of married women Model’s estimated number of infections from spouses
Estimates from the Modes of Transmission model (see reference 4)
People who are mutually monogamous 882,000 1,284,000 34,673
Married people who have casual partners 589,000 222,000
People whose spouses have casual partners 222,000 589,000 25,023
Clients of sex worker and wives of such men 388,000 388,000 16,978
 Men who have sex with men and wives of such men 14,000 14,000 14
Total married adults and total estimated infections from spouses according to the Modes of Transmission model 2,095,000 2,497,000 76,688
Alternate estimate recognizing that most HIV-positive married adults have HIV-positive spouses
Total married adults (from Modes of Transmission model) 2,095,000 2,497,000
Married and at risk to get HIV from a spouse (4% of married men, 5.7% of married women; see table12.10 in reference 5) 84,000 142,000
Estimated new infections (assuming a 6.6% annual rate of HIV transmission from wives to husbands and 9.9% from husbands to wives; see reference 2) 5,500 13,500 19,000

Thus, only 226,000 married adults (4% of husbands and 5.7% of wives) were at risk to get HIV from their spouses (see next to last row in the Table). How many of these 226,000 will get HIV from their spouses in a year? During the 1990s, 5 studies in Africa followed discordant couples (only one spouse HIV-positive) to watch HIV transmission from one to the other – distressingly, these studies did not routinely warn participants that they or their partner was infected. With few couples taking care to avoid transmission, 6.6% of HIV-positive wives infected husbands in a year, and 9.5% of HIV-positive husbands infected wives in a year (these rates are from a recent review [2]). With these rates of transmission, 226,000 HIV-positive married men and women in Malawi infected an estimated 19,000 spouses in 2007 – only 20% of the estimated 94,454 new HIV infections in Malawi in 2007.

The Modes of Transmission model’s gross and logically absurd overestimate of numbers of HIV infections from spouses is not harmless. Consider these damaging consequences:

1. Diverting attention from HIV risk in unsafe health care: If sex in marriage accounts for only 20% of new HIV infections instead of 81% as estimated by the Modes of Transmission model, then most infections need to be explained by other risks. What are those other risks? The Modes of Transmission model estimates that all non-spousal sex – casual, commercial, and male-male sex – accounts for a combined total of only 18% of infections. If all sexual risks account for only 38% of infections – 20% from spouses and 18% from other sex partners – what non-sexual risks account for the remaining 62% of infections? The Modes of Transmission model avoids this question by grossly overestimating numbers of HIV infections from spouses.

2. Stigmatizing HIV-positive adults: The estimate produced by the Modes of Transmission model – that sex accounts for more than 99% of HIV infections among adults – stigmatizes all HIV-positive adults with the charge they got it from sex. Publishing such estimates contributes to what could be considered a form of sexual abuse – spouses, relatives, and others accusing people of sexual behavior for which there is no evidence. The estimate coincides with racist stereotypes of sexual behavior, which protect it from critical review.

3. Undermining families: Stigmatizing all HIV-positive adults with the charge they got if from sex breeds suspicion among married adults when one or both learn they and/or their partner are HIV-positive. Lack of trust between spouses weakens families and harms children.

The motivation for such misinformation may be traced to a conflict of interest common among health care professionals – who do not want people to know that unsafe health care contributes to Africa’s HIV epidemics. Rather than admitting the obvious (and doing something about it), health care professionals have been blaming victims, insinuating that almost all African adults with HIV got it from sex. The Modes of Transmission model is part of that stigmatizing and racist smear.


1. UNAIDS. Modes of Transmission spreadsheet. Geneva: UNAIDS, 2012. Available at: (accessed 24 April 2014).

2. Gisselquist D. UNAIDS’ Modes of Transmission model misinforms HIV prevention efforts in Africa’s generalized epidemics. Social Science Research Network, 24 August 2013. Available at: (accessed 24 April 2014).

3. Gisselquist D. Misinformation from UNAIDS’ flawed Modes of Transmission model. dontgetstuck, 14 September 2013. Available at: (accessed 24 April 2014).

4. Maleta K, Bowie C. Selecting HIV infection prevention interventions in the mature HIV epidemic in Malawi using the mode of transmission model. BMC Health Services Research 2010; 10: 243. Available at: (accessed 22 April 2014). At the end of this article, see the link to Additional file 1: Data sources used to populate the Mode of Transmission model – Malawi 2007.

5. ORC Macro. Malawi Demographic and Health Survey 2004. Calverton: ORC Macro, 2005. Available at: (accessed 26 April 2014).