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Tag Archives: healthcare associated HIV

South Africa: With This Kind of Research, Who Needs Ignorance?

Following a recent article about HIV among ‘old’ people in Tanzania which I discussed a short while back, another article has appeared about an increase in HIV among people over 50, this time from Gauteng, South Africa. Prevalence in Gauteng is high, though it is not the highest in the country. The article concentrates, as is customary for articles about HIV, on sexually transmitted HIV, noting ‘unsafe’ sexual behavior, in addition to ‘caring for infected children’.

However the apparent lack of concern older people are said to feel about being infected, along with their ‘ignorance’ which the authors note, may stem from the fact that people in this age group do not engage in as much ‘unsafe’ sex as imagined, that the sex they engage in may not be as ‘unsafe’ as imagined, and that they may face many non-sexual risks as a result of not being informed about these; constant emphasis of sexual transmission and under-emphasis of non-sexual transmission doesn’t help either.

Are the researchers even aware that every skin piercing procedure could be a risk, not just reused injecting and other equipment, but also reused cosmetic instruments (tattooing, piercing, shaving) and reused instruments in traditional practices (traditional medicine, scarification, circumcision)? If older people do not, as the authors suggest, see themselves as being at risk of being infected with HIV, perhaps this is because the non-sexual risks they face through caring for HIV positive people, and risks they face themselves in healthcare, cosmetic and other facilities, have rarely been addressed by HIV intervention programs.

The most worrying aspect of this paper is that it is assumed that sex is the only, or the biggest risk, for HIV. This means that non-sexual risks, which may increase in older people who may have greater healthcare needs, are given so little attention that people do things which they don’t even realize are a risk. Worse still, those providing healthcare, cosmetic and traditional procedures may not realize the risks, or they may be a lot less vigilant in their day to day activities.

Despite the emphasis the authors put on sexual transmission, “using the same needles or sharp objects” was mentioned by at least one of the interviewees. Also, two traditional healers were among those interviewed and seemed aware of their risk to themselves, but not the risk that their clients face, which may be a lot higher. But the use of ‘protective clothing’ by those caring for HIV positive people is far too vague to be of any practical value. What about mentioning skin piercing procedures, needlestick injuries, reuse of needles, syringes, razors and other skin piercing instruments?

This seems to be another missed opportunity to address the substantial non-sexual risks people face from infection with HIV and other bloodborne diseases through skin piercing procedures, whether carried out for medical, cosmetic or traditional reasons. Older people, the subject of this paper, and others around them, may face increased risks from skin piercing procedures, especially those found in health facilities. Instead, the authors obsess about the purported sexual behavior of South African people and fail to make any recommendations about reducing non-sexual HIV transmission.

Why Contact Tracing is Vital in High HIV Prevalence African Countries

A recent blog post I wrote received some comments from ‘Brad’, at The Mosaic Initiative, a grassroots organization based in the US. Although Brad seems to think that what I wrote accords in some way with what he believes, it is quite clear to me that we both think very different things about HIV.

For a start, I believe that HIV epidemics in African countries are NOT like HIV epidemics in the US and other Western countries. The bulk of HIV transmission in Western countries is a result of either male to male sex or injected drug use. The bulk of HIV transmission in African countries is not a result of either of these, in any country.

The very point of the Don’t Get Stuck With HIV website and blog is that no African country has made a convincing estimate of the proportion of HIV transmission that is a result of sexual, as opposed to non-sexual transmission. It is just assumed that about 80% is a result of heterosexual sex and most of the remaining 20% is accounted for by mother to child transmission; these assumptions have been held for more than 20 years and emanate from WHO, the World Bank, UNAIDS and other institutions that control HIV funding, globally and in African countries.

I also disagree with Brad that it is merely “important to know how HIV is spreading”; it is vital to know whether someone was infected through sex, through unsafe healthcare, through some traditional practice or in a tattoo studio. There is no “generalized pandemic” that Brad speaks of. In Western countries, the vast majority of people are not at risk of being infected with HIV. Even in African countries some people are more likely to be infected than others; in Burundi HIV prevalence is low, but in Botswana it is high. In cities, even Bujumbura, prevalence tends to be high.

Prevalence is almost always higher among women than men in high prevalence African countries, higher among employed people than unemployed people, higher among wealthier people than poor people, etc. There is a huge level of heterogeneity, between and within countries. This heterogeneity does not seem to correlate very much with sexual behavior, though you may believe otherwise if you have immersed yourself in HIV industry literature.

For example, birth rates are high in Kenya’s Northeastern Province, condom use is low, education is low, poverty is high, intergenerational marriage and sex rates are high, all things thought to relate to high HIV transmission; but HIV prevalence is the lowest in the country, lower than in some US cities.

The problem with the approach of UNAIDS and others is not that they employ ‘targeting’, as Brad suggests, but that their assumption implies that all sexually active people who engage in heterosexual sex are equally at risk in African countries. You can’t ‘target’ everyone in a population, or even half or a quarter of hundreds of millions of people.

Although UNAIDS and others claim that the bulk of HIV transmission is a result of heterosexual sex between people in long term monogamous relationships, with the implication that one or both partners must have had ‘unsafe’ sex outside of their relationships, they do not carry out contact tracing, that is, investigating ALL the possibilities for how each person was infected.

Most of the emphasis is on sexual transmission, and even then, sexual partners are usually not tested; when they are tested the HIV types are usually not matched. Therefore, it is almost always unknown how each person was infected, even though it is almost always assumed, in the absence of data to prove it, that each infection was a result of ‘unsafe’ heterosexual sex.

Effectively, UNAIDS and others in the HIV industry are not targeting any group because they don’t have a clue where to look. They assume that almost everyone who is HIV positive engages in ‘unsafe’ sex; they also assume that anyone who engages in any kind of sexual activity they consider to be ‘unsafe’ is a ‘risk group’, and that IS every sexually active heterosexual (or heterosexual who has sex with heterosexuals, or whatever nomenclature you care to adopt).

HIV status is not an indication of sexual activity, ‘safe’ or ‘unsafe’; and sexual activity is not an indication of HIV status or HIV ‘risk’. People in the US and other Western countries may object to contact tracing but in African countries it is vital. It has been avoided in African countries precisely because some have decided that it is a ‘bad thing’, that it ‘stigmatizes’ people, but as a result ALL African people in high prevalence countries have been stigmatized. The situation in Africa is not like the situation in Western countries and the sooner the HIV industry realizes that, the better.

Tanzania: HIV Industry Still Failing to Collect Data on Non-Sexual Transmission

One of the many damaging consequences of assuming that HIV is almost always transmitted through usafe sex is that those working with HIV tend not to notice non-sexual transmission, such as through unsafe healthcare, traditional and cosmetic practices. This blog and site is littered with examples of these modes of transmission, and of the HIV industry studiously ignoring every instance of transmission that they can’t explain away as being somehow related to sexual transmission.

High rates of transmission among ‘older’ people, which refers to people who are more than 49 years old (my current age), always comes as a surprise to those working for the industry. The Victorian prudishness that seems to affect people working with HIV means that they believe everyone gives up sex at some arbitrary time in their lives. Bizarre!

But older people, and that means people over 50 in developing countries, where life expectancy is much lower than in Western countries, don’t only continue having sex. They may also require health services more frequently than younger people. While that may not surprise those in the HIV industry, they have had a lot of trouble with the notion that understaffed, underfunded, underequipped health facilities may not be able to provide the safest health services in the world.

Research carried out in Tanzania finds that HIV prevalence among people from 50-98 years was 7.8%, compared to the national figure of 5.1% for people aged 15-49 years. HIV prevalence was higher in urban than rural areas, in common with figures for Tanzania as a whole [note that this is the opposite to what is stated in the abstract but I’m assuming the following text and data are correct]. While prevalence was a very high 12.9% among people 50-59 years old, it dropped to 5.7% among the 60-69 years age group and 3.7% among the 70+ age group.

The two areas for which data was collected, Mufindi and Babati, are in one of the highest (Iringa) and one of the lowest prevalence regions (Manyara), respectively, in mainland Tanzania. Prevalence among 50-98 year olds was 3.7% in Babati and 11.3% in Mufindi. The figure for Mufindi is not so shocking compared to Iringa’s 9.1% prevalence; in contrast, the figure for Babati is more than double the figure for Manyara region, which stands at 1.5%.

But it’s a pity the breakdown for male and female figures for each area is not available. The ratio of female to male prevalence in Iringa is 63%, similar to the national figure of 61%. But the same ratio in Manyara is 11%; there are about 9 HIV positive women for every HIV positive man. Is this shocking ratio maintained among people between 50 and 98 years old?

As is usual with these studies, no data was collected about non-sexual transmission, whether through unsafe healthcare, traditional or cosmetic practices. While the authors conclude that interventions should now target ‘older’ people, they fail to consider non-sexual HIV transmission, which means that some of the most important risk factors will continue to be ignored, and HIV will continue to be transmitted, independent of anything the HIV industry spends its millions on.

Borborygmus: Recent Contributions to HIV Epidemiology

David Gisselquist has already written a critical reaction to Jacques Pepin’s latest attempt to rewrite the history of HIV and unsafe injections. But AidsMap has gone in the opposite direction, by writing a completely uncritical, triumphalist regurgitation of Pepin’s paper, without finding anything strange about this ‘study’.

It’s odd enough that Pepin’s findings happen to match earlier claims from him and others, some made quite a number of years ago, as if simply wishing away HIV transmission through syringe and needle reuse were enough to almost eradicate it completely.

But in the ten year period Pepin is dealing with, sexual transmission has received almost all the attention and funding; yet the contribution of sexual transmission must have increased if Pepin is correct. At the same time, non-sexual transmission, which has yet to be addressed, even acknowledged by the HIV hierarchy, has dropped by almost 90%, a truly etymological decimation.

Pepin’s estimations, the provenance of which are very unclear, fly in the face of data collected by the Kenya Aids Indicator Survey. A paper using data from this survey finds that men who have had one or more injection in the previous 12 months were three times more likely to be HIV positive and women were two and a half times more likely.

The minute number of HIV transmissions that Pepin estimates were a result of unsafe medical injections in a year globally, 17,000-34,000, could be closer to the number of HIV transmissions in Kenya alone that were transmitted through various non-sexual routes.

Vague proportions of HIV transmission through sexual and non-sexual modes are estimated using the thoroughly flawed Modes of Transmission Model, which is well criticized on this site. So it remains a mystery what Pepin is talking about. Kenya is unlikely to be the only country where unsafe healthcare contributes a substantial proportion of HIV transmissions; but it is one of the few countries in Africa that has carried out any research into this phenomenon.

Prejudice Continues to Blind UNAIDS to Non-Sexual HIV Transmission

Perhaps the author means well by speculating about how much ‘sodomy’ there is in Zambian prisons. But articles like this miss a great opportunity to look at possible non-sexual HIV risks in prisons. For example, what are safety standards like in prison health facilities? Do prisoners engage in cosmetic practices, such as tattooing, piercing, even shaving and hairdressing? Do any of them engage in traditional practices that may involve skin piercing or cutting? Do any engage in blood oaths or anything else that could result in a HIV negative person coming into contact with the blood of a HIV positive person?

The article says that “homosexuality is among the six key drivers of the transmission of HIV in” Zambia. One source lists these drivers as: multiple and concurrent sexual partners, mother to child transmission, low and inconsistent condom use, vulnerable and marginalized groups, low rates of male circumcision and mobility and labour migration. Let’s look at each of them in turn.

No non-sexual ‘drivers’ are clearly identified there. But the list is a very weak tool for identifying the risks that many people face, given that prevalence reaches over 20% in the capital, Lusaka, and close to that figure in two other provinces. For example, several articles have shown that having multiple partners does not account for extremely high rates of HIV transmission; concurrent partnerships are no higher in high prevalence areas than in low prevelence areas, but they can not account for very high rates of transmission either, despite the frequent, triumphalist literature spewed out on the subject.

Many women are infected fairly late in their pregnancy or just after giving birth, when they are unlikely to have engaged in any kind of sexual behavior, let alone unsafe sexual behavior; and the partners of many women who seroconvert are HIV negative. In addition, some women are infected by their infant, who could only have been infected by some kind of non-sexual route, such as unsafe healthcare. We have no idea how common this phenomenon is.

HIV prevalence in many countries is higher among those who sometimes use condoms and lower among those who say they never do. Condom use only protects against sexual transmission of HIV, not against non-sexual transmission. The issue of circumcision is highly controversial and it has never been shown that the mass male circumcision programs currently being carried out in high HIV prevalence African countries will have any impact on HIV transmission, except by the use of dubious figures conjured up by those who believe that circumcision is superior to the alternative, which involves not slicing off a healthy piece of genital flesh.

Mobility and labor migration are perhaps more closely related to ‘vulnerable and marginalized groups’ in Zambia because HIV prevalence is exceptionally high among those involved in mining, for example. Many miners are mobile, many are immigrants, and high levels of HIV prevalence means that they are singled out for stigmatization by the HIV industry, which insists that HIV is almost always transmitted through unsafe sex. Therefore these high prevalence groups must be promiscuous, also careless, selfish, predatory and a whole lot of other pejorative things.

The HIV industry continues to stigmatize people who are often already marginalized, blame people who are infected and alienate people who are most vulnerable to suffering from poor health, facing many other hazards relating to health, poverty, education and employment. There are two ‘drivers’ of HIV epidemics, sexual and non-sexual. The industry concentrates on sexual transmission to the almost total exclusion of non-sexual transmission. This needs to be addressed if countries like Zambia are to reduce HIV transmission, especially in prisons and mining areas, and eventually eradicate it altogether.

[For more about non-sexually transmitted HIV through unsafe healthcare, cosmetic and traditional practices and how to protect yourself, visit the Don’t Get Stuck With HIV site.]

HIV Transmission Via Unsafe Medical Injections in Kenya – Significant Risk

Congratulations to Kenya on being one of the first African countries with a serious HIV epidemic to investigate the role of unsafe healthcare and reuse of injecting equipment in transmitting HIV. The study finds that “Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months.

But these findings make the conclusion of the article all the more striking: “Injection preference [my emphasis] may contribute to high rates of injections in Kenya.” If someone is infected with HIV as a result of receiving an injection, then it is the behavior of the health care practitioner that is at fault, not the ‘preference’ of the patient. Health facilities make more money from procedures such as injections than they do from just giving advice or handing out prescriptions, so there may be good reasons why patients ‘prefer’ injections; they may have been led to believe that injections are ‘better’. I’d also be surprised if mere patient preference made much difference to the kind of treatment a patient received in Kenya or elsewhere in East Africa.

Those providing health services need to take responsibility for healthcare associated HIV transmission, and that includes Ministries of Health, professional bodies, and also the WHO, UNAIDS, CDC and other parties who have dominated health and HIV policy in high HIV prevalence countries for decades. Reuse of syringes, needles and other skin piercing equipment carries a very high risk of transmission of HIV, hepatitis and other pathogens. It is not enough to blame patients for their ‘preferences’. Practitioners can decide what treatment a patient needs and what is the best means of administering it, if that means is available to them.

The paper recommends that “community- and facility-based injection safety strategies be integrated in disease prevention programs”. If this is UN-speak for the need to accept that HIV is frequently transmitted through unsafe healthcare and these practices need to stop, then I wholeheartedly agree. This is more than thirty years too late, but it’s good to hear the very mention of non-sexually transmitted HIV in the form of unsafe healthcare being taken seriously in a peer-reviewed journal. I look forward to hearing of other high HIV prevalence countries making the same ‘discovery’ and publicizing it, and also taking steps to reducing such transmission risks.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don’t Get Stuck With HIV site’s Healthcare Risks for HIV pages.]

Uganda: Mystery About Effectiveness of Circumcision Against HIV

The HIV industry’s circumcision division has put a lot of effort into denying that circumcised men may feel that they can safely engage in ‘risky’ sexual behaviors. But some peer reviewed articles have found that circumcised men feel that, being circumcised, they are not at risk of sexually transmitted HIV, or that their risk really is lower as a result of being circumcised.

The problem is, how do they know how circumcised and uncircumcised men become infected? They may believe the HIV industry’s mantra about almost all HIV transmission being a result of unsafe sex in African countries, but nowhere else. But what if the HIV industry is wrong? They have never checked. They have never traced people’s partners systematically or assessed their non-sexual risks, from unsafe healthcare, traditional and cosmetic practices, they have never investigated infections that were clearly not sexually transmitted.

The industry seems to feel that the end justifies the means because HIV prevalence has turned out to be lower among circumcised men in some circumstances. But if they don’t know how some men, circumcised and uncircumcised, became infected, how do they know that circumcision protects them? If circumcision is associated with higher HIV prevalence in some countries and lower prevalence in other countries, perhaps circumcision status is irrelevant. Perhaps sexual behavior is irrelevant, the HIV industry just doesn’t know.

So millions of men are said to be lining up to be circumcised and they don’t know whether it will really protect them, whether it will increase their risk or whether it will have no effect at all. They also don’t know how safe conditions are in the clinic where the circumcision is carried out.

[For more about the ineffectiveness of Male Circumcision against HIV visit our circumcision related pages.]

Control Element More Evident than Prevention in Uganda’s HIV Bill

Another article on Uganda’s idiotic HIV/AIDS Prevention and Control Bill says the country is going have a bill that compels men to test for HIV along with their partners when their partners are pregnant. I can see a lot of fatherhood denials resulting from this. But this bill, which claims to be punishing men (who all deserve to be punished, right?), will be a lot more threatening to women.

HIV prevalence is higher among women (8.3%) than men (6.1%) and women are already under a lot of pressure to be tested for HIV when pregnant. This means that a lot more women are aware of their status and it is unlikely they will be able to claim not to know their status if they have ever been pregnant, especially if they live in an urban area (urban prevalence 8.7%, rural 7%) and can afford some healthcare (richest quintile prevalence 8.2%, poorest quintile 6.3%).

Ugandan politicians are probably not aware of the terrible conditions in health facilities in their country as they and their families always seem to go abroad when they need healthcare. But they should be aware that health facilities there, especially reproductive health facilities, may be dangerous places. A very expensive survey is carried out every now and again called the Service Provision Assessment and they should familiarize themselves with it. Almost all Ugandan women attend an antenatal facility at least once, and more than half give birth in a health facility and receive the assistance of a skilled health professional.

Given such conditions in healthcare facilities, maybe Ugandan politicians should make sure HIV and other diseases are not being transmitted through healthcare and other skin-piercing procedures before passing a bill that seems to assume that transmission is all a result of unsafe sex. They don’t seem to have any idea of the possible consequences of such a bill.

[There have been quite a number of HIV infections in Uganda that have been unexplained by sexual behavior and are probably healthcare related. To read more, visit our Cases and Investigations page for Uganda.]

South Africa Continues to Fail to Reduce HIV Transmission

UNAIDS is strange, perhaps stranger than their numerous UN siblings. They have a single disease as their brief and they have spent 20 years learning next to nothing about it. They keep collecting data about sex, because they insist that HIV is almost always transmitted through unsafe sexual behavior in high prevalence African countries, but nowhere else. They have to shore up their arguments by appealing to prejudices, such as popular beliefs about ‘African’ sexuality, the brutish mentality of African men (yes, all of them) and the pathetic victim status of African women.

So it comes as a bit of a shock to them when they accidentally carry out research that casts doubt on their fondly held prejudices. A paper entitled ‘Sexual relationship power is unexpectedly not associated with unprotected sex in tavern populations in South Africa‘ is a case in point. Of course, alcohol abuse is a terrible social problem in South Africa (and many other countries), and needs to be addressed urgently. So is violence against women, gender based crime and a whole host of other social problems that are endemic in countries with a large proportion of very poor people who live in virtually uninhabitable environments.

UNAIDS is almost as old as South Africa’s epidemic, where prevalence stood at less than 1% in 1990 but rose rapidly to more than 25% over a decade ago and has not dropped below that figure since [I should clarify, these figures are for antenatal clinic attendees, not for the male and female 15-49 year old population, among whom prevalence is 18.8%]. The yearly HIV reports that South Africa shoves out are almost entirely about sexual behavior, with next to nothing about non-sexual transmission of HIV, via unsafe healthcare, cosmetic and traditional practices. I wonder how long it will take before anyone notices that they clearly haven’t even started to understand the worst HIV epidemic in the world.

[For more about sexual transmission risks and HIV prevention, have a look at some estimated risks from various sexual practices.]

What Kind of HIV Risks do Public Sector Employees Face? Sexual? Non-Sexual?

An article in the Arusha Times claims that public sector employees may be more vulnerable to HIV. This is not too surprising because HIV prevalence is higher among employed than unemployed people in Tanzania and a lot of other higher prevalence countries. Prevalence is also higher among urban dwelling people, wealthier people, and various other groups.

But the question is, why is their risk higher, often much higher? One of those cited in the article is said to have urged “married couples to go for tests on their HIV status without any suspicion on who among the two was to blame in case he or she tested positive”. Maybe neither are ‘to blame’. Many HIV positive people are married to or living with only one, HIV negative person. They don’t know how they were infected. However, the HIV industry insists that they were almost definitely infected through unsafe sex. Perhaps public sector employees face non-sexual risks, such as those from unsafe healthcare, traditional or cosmetic practices?

[There have been a number of unexpected infections in infants and young adults in Tanzania in the 1980s and 1990s and these may have been cases of healthcare associated HIV, but they have yet to be investigated.]