Bloodborne HIV: Don't Get Stuck!

John Potterat, a senior and well-published international expert on sexually transmitted diseases, has taken part in scientific debates about the relative contribution of sex vs. blood (injections, tattooing, etc) in Africa’s HIV/AIDS epidemics. He’s been frustrated for years. The loudest voices with the most money talking about HIV/AIDS in Africa — UNAIDS, WHO, USAID, Gates, and others — want to blame it all on sex. But they haven’t got the evidence to support what they say and what they want everyone to believe. Why are so many scientists who build their careers on HIV/AIDS in Africa so unscientific, so uncurious, and so careless about what they say and about the evidence?

Earlier this month, John Potterat published a brief but pointed and thoughtful critique of HIV research in Africa. You can download his article free from the SSRN website: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2310200

As a teaser, here’s the Abstract of the article:

The Enigma of HIV Propagation in Africa: Mainstream Thought Has Narrowly Focused on ‘Heterosexual Sex’

John J. Potterat, Independent consultant
August 14, 2013

Abstract:

Introduction: Three decades after the identification of AIDS, epidemiologists still do not fully understand HIV transmission dynamics in sub-Saharan Africa, nor its differential geographic and demographic spread.

Discussion: Despite mounting evidence suggesting a substantial role for nonsexual (puncturing) exposures in HIV transmission, researchers have not systematically investigated its impact on HIV propagation in Africa. Mainstream researchers initially reacted to this idea skeptically, then dismissed it in the short run as apostasy and chose to ignore it in the longer run. This research design flaw has been the Achilles Heel of efforts to explain the rapid propagation of HIV in Africa, a flaw that continues to this day — much to the detriment of scientifically trustworthy interventions.

Conclusion: A science that ignores potentially important modes of transmission, especially when confronted by challenging and respectable evidence, is inadequate and needs remedial attention.

Despite the constant claim from UNAIDS and the HIV industry that HIV is almost always transmitted through unsafe heterosexual sex in African countries, though nowhere else in the world, it has yet to be demonstrated how appalling conditions in hospitals in high HIV prevalence countries hardly ever result in HIV and other serious diseases being transmitted. After all, relatively unsafe conditions in Western countries have resulted in incidents of healthcare transmitted HIV on numerous occasions. TB has been transmitted in hospitals in South Africa. So why not HIV and other bloodborne diseases?

A recent audit carried out in South African hospitals found that 93% of maternity wards are not safe for mothers or babies. This is no surprise to people who have frequently commented on the fact that HIV prevalence is often higher among women who give birth in health facilities than it is among women who give birth at home. But South Africa has the highest HIV positive population in the world. Do UNAIDS and the HIV industry really want to stick to their contention that these conditions hardly ever result in HIV transmission?

In the past, UNAIDS’ response has been that they would prefer to see people attending health facilities, as it is better for their health. But there is a lot of evidence that health facilities are not safe places. Even the UN itself has issued guidance to their own employees to carry their own medical equipment when working in high HIV prevalence countries, as safety in health facilities can not be guaranteed unless they are ‘UN approved‘. So they can’t have it both ways: if health facilities are unsafe for UN employees, they are unsafe for South Africans.

In the absence of any other explanation, I would suggest that UNAIDS and the HIV industry exhibit a profound form of institutional racism and sexism (because far more women are infected with HIV than men). I could be wrong and the industry may have the best interests of South Africans at heart. But if that’s the case, why is almost all the industry’s literature about sexual behavior and a few other things considered to be illicit or even illegal, such as intravenous drug use, male to male sex and commercial sex work?

HIV transmission through contaminated blood is extremely efficient, which is why intravenous drug use is so dangerous. But the highest use of syringes and other skin piercing instruments is found in health facilities (and also in traditional medicine practices, pharmacies, hairdressers, tattoo parlors and various other contexts to which UNAIDS and the industry appears to be completely blind). Hundreds of millions of injections are given every year; the majority are either unnecessary or the treatment could be administered non-invasively.

Apparently the maternal mortality rate is a massive 310 deaths per 100,000 live births in South Africa. In addition to threatening the lives and health of mothers, these conditions threaten the lives and health of babies and young children too. People are not made aware of the dangers of hospital transmitted infections. And what hospital transmitted infection could be more of a risk in extremely high prevalence areas than HIV? The virus tends to be far more common in built up areas, close to main roads and hospitals. In contrast, it tends to be a lot less common in more rural and isolated areas.

Yes, people need accessible healthcare, but no, not at all costs. If healthcare is unsafe, as it clearly is in South Africa and many other African countries (where conditions can be so bad that most people don’t use health facilities, and HIV prevalence is a lot lower), this will not reduce the transmission of HIV or other diseases. The worst place to go if you want to avoid a transmissible disease is a hospital if conditions there are as bad as they are in most African countries. Indeed, some epidemics, such as ebola, have hospitals as their epicenter, and the epidemic is only stopped when the hospital is closed.

This is not to say that all health facilities are dangerous, though the majority of them seem to be in South Africa. Nor is it to say that all healthcare workers could be doing more harm than good, though a lot seem to be doing harm in South Africa. Congratulations to the country on publishing the report, but it won’t do anyone any good until people are aware of the risks they face, and especially of the fact that HIV is not always transmitted sexually. Some of the worst HIV epidemics were almost definitely started by unsafe healthcare practices. How do we know that these same practices are not still contributing to some of the worst epidemics?

Out of 3,880 hospitals audited, some other findings include:

• Only 32 of the facilities audited complied with infection prevention and control;
• Only two facilities could guarantee patients’ safety;
• Just 161 facilities were clean enough to meet the audit’s tough standards; and
• Staff attitudes towards patients were awful – just 25% of staff in clinics were found to embody positive and caring attitudes

It’s time to stop treating South Africans and other Africans as if they are somehow different from non-Africans, as if their sexual behavior is almost uniquely dangerous, as if everyone who is HIV positive must have engaged in some kind of illicit behavior. People need to know that hospitals are dangerous places so they can take steps to avoid being infected with HIV, TB, hepatitis or any other disease while in hospital. That means UNAIDS and the HIV industry need to give up their obsession with ‘African’ sexuality, sexual behavior and sexual mores. It’s not all about sex, so let’s act accordingly.

Health care professionals in African ministries of health, the World Health Organization (WHO), donor organizations, and foreign universities participating in HIV-related research in Africa know the proper response to unexpected HIV infections (eg, in children with HIV-negative mothers, in spouses with one lifetime HIV-negative sex partner). That response is to find the source of the infection by tracing and testing others who attended suspected hospitals and clinics, and thereby to identify and correct unsafe practices to protect other patients. There have been no such investigations of unexpected HIV infections in any country in sub-Saharan Africa.

Health care professionals are ethically obligated to give patients accurate information about risks. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient[1] states: “A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions…” and “Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services.”

Medical researchers trying to find what is different about HIV transmission in Africa that could explain the world’s worst HIV epidemics know that the best way to do so is to trace and test sex and blood contacts when someone shows up with a new or unexplained infection. Unfortunately, medical researchers (who are also health care professionals) have been reticent to find their colleagues’ contribution to Africa’s HIV epidemics. For example, 44 studies[2] that followed more than 120,000 adults in Africa and observed more than 4,000 new HIV infections linked only 186 (4.6%) of those infections to HIV-positive sex partners, all of which were spouses the study had been following all along. No study traced and tested any sex partner (spouse or other) not already included and followed in the study. No study traced blood contacts, and few studies reported any information about blood risks. Despite lack of evidence (avoided and ignored evidence) all studies assumed infections came from sex. (These 44 studies were randomized controlled trials of interventions to prevent HIV in African adults.)

For 30 years, medical professionals have accused HIV-positive Africans of careless or immoral sexual behavior. But if one looks for what is different in Africa vs. the US and Europe, what jumps out is not sexual misbehavior but rather unethical, immoral, and incompetent behavior by health care professionals: not investigating unexpected HIV infections; not warning the public about unsafe health care; and mismanaging research so as not to find risks for HIV.

Ten years ago, on 14 March 2003, WHO held a one-day meeting to discuss the role of unsafe medical injections in Africa’s HIV/AIDS epidemics. WHO staff arranged the meeting after a series of articles[3][4][5] in the International Journal of STD & AIDS during 2002-03 called attention to decades of overlooked evidence that unsafe health care infected Africans with HIV. The 20 invited attendees[6] included three co-authors of these articles (Brody, Gisselquist, and Potterat).

WHO staff managed the meeting as part of a continuing cover-up of hospitals’ and clinics’ contribution to Africa’s HIV epidemics. The meeting was closed to the public. A first press release, prepared by WHO staff in the days before the meeting and released before it ended, misleadingly claimed:[7] “An expert group has reaffirmed that unsafe sexual practices are responsible for the vast majority of HIV infections in sub-Saharan Africa…”

Later that year, WHO’s meeting summary[8] acknowledged that “No consensus emerged from the conference” on whether “sexual transmission was responsible for the large majority of HIV infections.” The summary also noted “universal agreement…that better data on the possible role of unsafe injections, and other health care practices, in HIV transmission are needed to more definitively determine their role in HIV transmission in sub-Saharan Africa.”

Unfortunately, the events of the last 10 years show a continuing unwillingness on the part of too many health care professionals to do what is needed to find and stop HIV transmission through unsafe health care in Africa.

According to George Ochoa “An infection spread by unsafe injection practices can happen anywhere” and finds that “Since 2001…at least 48 outbreaks caused by unsafe injection practices have occurred in the United States, with the majority (90%) in outpatient settings (10 in pain clinics and nine in oncology clinics). Twenty-one of the outbreaks involved hepatitis B or hepatitis C; 27 were bacterial. More than 150,000 patients required notification to recommend bloodborne pathogen testing following exposure to unsafe injections.”

But if UNAIDS is right, George Ochoa is wrong; HIV infections through unsafe injection hardly ever occur in high HIV prevalence countries, which are mostly in sub-Saharan Africa. That must explain why, since the HIV epidemic began 30 years ago, no outbreak investigations have been carried out in sub-Saharan Africa.

UNAIDS’ ‘Kenya Aids Epidemic Update 2011’ briefly mentions re-use of injecting equipment during immunization programs (which account for a small percentage of all injections administered). They say “In a study of young men (ages 18–24) in Kisumu, men who received a medical injection in the last six months were nearly three times more likely to be HIV-positive”.

However, the report also claims that a minuscule percentage of HIV infections were a result of any kind of unsafe healthcare and that “Sexual transmission accounts for an estimated 93% of new HIV infections in Kenya, with heterosexual intercourse representing 77% of incident infections. Adults in stable, seemingly low-risk heterosexual relationships make up the largest share of new HIV infections.”

Did they assess the non-sexual risks faced by those people in ‘seemingly low-risk’ relationships? The report says “Among adult participants in the 2003 Kenya Demographic and Health Survey who said they had “no risk” for HIV, nearly 1 in 20 (4.6%) were in reality HIV infected”. The implication is that all those people were infected sexually, but they just didn’t realize they were at risk. For the authors of the UNAIDS report, the people in question were either stupid, liars or stupid liars.

The report recognizes that if there is a large number of HIV positive people in the population, the risk for each sex act is higher. But they don’t acknowledge that the same circumstances also make the risk of infection from an unsafe injection or other skin piercing procedure far higher. HIV prevalence is about 10 times higher in Kenya than it is in the US. But there have been no reported outbreaks of HIV or any other disease as a result of unsafe healthcare in Kenya or any other sub-Saharan African country.

Another study, by WHO, says that “around half the injections used across the world are unsafe for administration, with a worse ratio in developing countries”. So is it possible that George Ochoa is right in stating that “An infection spread by unsafe injection practices can happen anywhere”, and UNAIDS wrong? Well, shocking as it may seem to those who look to UNAIDS as an institution that specializes in HIV, what they say to Africans is different from what they say to UN employees.

Here’s what they have to say to UN employees: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. 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. 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.”

They also say: “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.”

I don’t know about anyone else, but I tend to believe the warning they give to UN employees, but that suggests they are lying about the risk that Africans face from unsafe healthcare. Why would this august institution lie about a very serious risk of HIV infection in the highest HIV prevalence countries in the world? Well, I can’t answer that question. If it’s vital to warn UN employees, it should be vital to warn those who don’t actually have much choice about which health facilities to use, UN approved or otherwise.

UNAIDS’ current touchy-feely campaign is called ‘Getting to Zero: zero new infections, zero discrimination, zero Aids related deaths’. How about ‘zero lies, zero double standards and zero institutional racism’ as an alternative set of objectives?

I know infection control professionals are not common in African countries but I hadn’t realized that up till recently there were none at all in Uganda. I wonder how many there are in countries that have received only a fraction of the funding Uganda has received, especially HIV funding. A WHO article about their ‘African Partnerships for Patient Safety’ initiative announces that one hospital, seven hours drive from the capital city, now “has its own infection control professional, the first in the country”. The article proudly states that “just two years ago, patient safety was an obscure concept that was almost impossible for hospital staff to apply when faced with practical realities”.

Could this be the same WHO that tells us that the vast majority of HIV infections in Uganda are a result of unsafe sex? True, the fact that patient safety was an ‘obscure concept’ does not mean that HIV transmission through unsafe healthcare is common. Rather, it means that we, WHO included, have no idea whether such transmission is common or not. We don’t know what proportion of HIV transmission is a result of unsafe healthcare and, therefore, what proportion is a result of the WHO’s beloved sexual transmission. Not that this stops WHO, UNAIDS and others from droning on about African sexual practices, ‘dry sex’, concurrency, circumcision, widow inheritance, long distance truckers, commercial sex workers and the rest, as if that’s all there is to HIV epidemics where many of the people infected face little or no obvious sexual risk.

The most striking thing about the official Modes of Transmission Survey for Uganda is that the largest group contributing to new infections consists of people in stable heterosexual couples. In many of those couples the index partner, the one infected first, is female (fewer males are infected but there is equally little evidence that they were all infected through unsafe sex). As the first to be infected, these women could not have been infected by their partners. So how were they infected? According to UNAIDS and WHO thinking, they must have had sex with someone other than their partner. The UN’s IRIN news service refers to them as ‘cheaters’, which is a reflection of IRIN’s typical style and level of sensitivity. But can the Modes of Transmission Survey rule out non-sexual transmission of HIV through unsafe healthcare, traditional and cosmetic practices in this group of people who face such low sexual risk? The simple answer is ‘no’. For UNAIDS, WHO and other institutions, it is simply taken for granted that the bulk of transmission is through unsafe sex. Questions about non-sexual risks are rarely raised and peremptorily dismissed if mentioned.

Survey after survey shows that those who engage in unsafe sex are no more likely to be infected that those who don’t; often, those who don’t engage in unsafe sex are more likely to be infected. High HIV prevalence does not tend to cluster in isolated areas, except where there have been major health programs. It does tend to cluster among wealthier, better educated, more mobile, employed people who are close to major transport routes and close to or in major cities; coincidentally, they also tend to be much closer to health facilities. Is one infection control expert in an isolated hospital in Uganda going to make much difference to transmission rates? Possibly in that hospital. But it is the initial assumption made by WHO, UNAIDS, etc, that needs to change: knowing someone’s HIV status tells you nothing about their sexual behavior and knowing about their sexual behavior is not a good predictor of their HIV status.

That may sound counter-intuitive if your ‘intuition’ is based on reading mainstream press, and even much of the more specialized scientific literature. HIV in African countries is almost invariably associated with sexual behavior. In Western countries this is not the case. HIV in wealthier countries tends to be attributed to intravenous drug use and male to male sex. Even in Asian countries, people are sometimes given a little benefit of doubt; they may have been infected through unsafe healthcare. But in African countries with the worst epidemics, there has never been an investigation into healthcare practices; there has never been an investigation into why so many women in Uganda (for example) are infected when their husbands are not, and where these women did not face any other obvious risks; there has never been an investigation into why so many babies are infected when their mothers are not; in fact, what proportion of babies are infected whose mothers are not? We don’t know the answer to these questions we appear not to even want to ask.

Does the ‘African Partnerships for Patient Safety‘ indicate an admission that patient safety could be a factor in some of the world’s worst HIV epidemics, after thirty years of insisting that HIV is all about sex and wasting billions of dollars accordingly, or is it mere lip service? I won’t be holding my breath.

[Cross-posted from the HIV in Kenya blog.]

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I’d like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It’s not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various ‘initiatives’ aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting ‘cheaters’. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be ‘cheaters’ could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It’s certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don’t know they are infected. It must also be remembered that most people don’t realize that there are significant non-sexual risks; if they don’t know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people’s worries in countries like Ethiopia, but only because many people don’t attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don’t Get Stuck With HIV site.]