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Misinformation from UNAIDS’ flawed Modes of Transmission model

To defeat HIV/AIDS in Africa, UNAIDS recommends: “Know your epidemic.” The best way to do so is to investigate to trace the source of infections – especially in children with HIV-negative mothers, virgins, and married people with HIV-negative spouses and no outside partners.

But that’s not what UNAIDS urges African governments to do. Instead, UNAIDS urges governments to use its Modes of Transmission (MOT) model to estimate numbers of infections from various risks.

But the MOT model contains a glaring error. Because of this error, whoever uses the model ends up estimating far too many infections coming from spouse-to-spouse transmission.

In Uganda, for example, the MOT model estimates that 60,948 married adults got HIV from their spouses during 2008. This is two-thirds of the model’s estimated total new infections from all risks in Uganda in 2008.

The MOT model got this number by supposing that 5.9% of married adults (421,000 adults) were HIV-negative with HIV-positive spouses, and that 14.5% of these spouses at risk got HIV from husbands or wives in 2008 (60,948 = 14.5% x 421,000).

But the number of spouses at risk is far, far less. Uganda’s 2004/5 HIV/AIDS Sero-behavioral Survey reports that 6.2% of husbands and 5.2% of wives were HIV-positive.  But – and this is the important fact the MOT model ignored – most HIV-positive husbands and wives were married to each other. Only 2.8% of wives and 1.8% of husbands were HIV-negative with HIV-positive spouses.

Overall only about 2.3% of married adults (averaging 2.8% of wives and 1.8% of husbands) were HIV-negative with HIV-positive spouses – only 222,000 vs. the 421,000 estimated in the MOT model. If 14.5% of these 222,000 adults got HIV from their spouses in a year, that would account for 32,100 new infections (14.5% x 222,000), far less than the 60,948 estimated in the MOT model.

Why is this important? Because if fewer infections are coming from spouses, how did so many Ugandans get HIV in 2008? In other words, the MOT not only over-estimates HIV from spouses, but also underestimates infections from other risks.

What risks are underestimated? Hold on now! Don’t run away with sexual fantasies about young people and some married adults having too much fun with non-spousal partners. Indulging in racist and stigmatizing sexual fantasies is something too many official AIDS experts like to do. But the evidence does not support such fantasies. The best information on sexual behavior does not come close to explaining Uganda’s epidemic.

Setting aside sexual fantasies, the underestimated risks are more likely to be those that UNAIDS’ staff and other health professionals want to ignore – skin-piercing procedures with unsterile instruments, such as injections, dental care, manicures, etc. This is true not only in Uganda but also in more than 15 other African countries that have used the MOT model to get ridiculous figures on numbers of HIV infections from spouses.

Remember how we began: The best way to “know your epidemic” is to trace infections. Let’s challenge HIV/AIDS researchers — finally — to do their job. Although it’s decades too late, tracing is still needed to find all the important risks and to stop Africa’s generalized HIV/AIDS epidemics.

[Note: This blog summarizes evidence and arguments in: Gisselquist D. UNAIDS’ Modes of Transmission model misinforms HIV prevention efforts in Africa’s generalized epidemics, available at:]

Mainstream scientists have not explained Africa’s HIV epidemic. Why not?

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:

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


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.

Cock-ups happen. Parental Advisory: Read this first – your baby can’t

This is a guest blog by Jim Thornton, re-posted from This reposting does not include the disturbing pictures of mutilated baby’s penises. To see the complete posting with pictures, go to:

The World Health Organisation Manual for Infant Circumcision’s (available at: sample information sheet for parents (p. 110) is not adequate. Here is the bit on surgical harms:

Complications during male circumcision are rare, being estimated to occur in 1 of every 500 procedures. These complications, which can be severe, include poor cosmetic outcome, bleeding, infection, injury to the penis and the removal of too much or too little skin.

Using “rare” for a 1 in 500 risk, when earlier the benefit of “avoiding the need for circumcision later in life” (about 1 in 2,000) is mentioned without qualification, is biased. The figure also applies to the best series. Less well organised services report rates up to 20%, e.g. Nigeria, available at: Since the manual is for use in developing countries the possibility of higher complication rates should be mentioned. Finally, Complications, which can be severe, include poor cosmetic outcome… is clearly designed to play down severity.

But more importantly, catastrophic complications are omitted altogether. Fully informed consent means telling people everything, however rare, which might alter the decision of a reasonable patient/parent. In gynaecology we mention the 1 in 10,000 risk of temporary colostomy after laparoscopic surgery for example. Unless we have a double standard for Africa, the complications below, which all appear elsewhere in the guide, should be mentioned. Italic text and pictures are all taken from the guide.

HIV, and other blood borne infections.

In male circumcision programmes a major concern is the potential transmission of bloodborne […] HIV and hepatitis B virus, to […] patients. The risk of acquiring HIV from an HIV-infected person through a needle-stick injury is estimated at 0.3% […] . The risk of acquiring hepatitis B virus infection, after being stuck with a needle that has been used on a person with hepatitis B infection, ranges from 6% to 37%, […] Most instances of transmission of infection in health-care facilities can be prevented through the application of standard precautions. If “it is a major concern” and only “most […] can be prevented”, it should be mentioned.

Amputation of the penis [picture available at]

This extremely rare complication can be minimized by using good surgical technique but is unlikely to be eliminated. Unfortunately, even under ideal circumstances and with experienced surgeons [it] continues to occur.

Destruction of the penis by electro cautery.

One should NEVER use an electric current [..] with a metal Gomco clamp. […] The use of electrocautery […] has resulted in total ablation of the penis during male circumcision. To avoid this devastating complication, surgeons must be educated that electrocautery has to be strictly avoided when using a Gomco clamp.

Urinary retention from retained Plastibell rings.

Some of the most serious complications ever seen [retention and bladder rupture] […] have resulted from retained Plastibells. Educating the family to closely monitor the wound and the infant’s urine output is paramount with the use of this device.

Penile necrosis following the Plastibell technique [pictures available at]

These two poor fellows aren’t going to be great in the sack.

Degloving – removal of the skin of the shaft [picture available at]

None of these complications are common, but they all occur. If infant circumcision programmes get rolled out widely in developing countries, it is inconceivable that everyone will read all 140 pages of the WHO manual In the real world sterilisation goes wrong, mismatched Yellen clamps get packed together, and diathermy and wrong sized Plastibells get used. Even if they don’t, infants wriggle. Parents should be told.

93% of South African Maternity Wards Unsafe for Mothers and Babies

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.

10 years later: Continuing unethical and incompetent behavior by medical professionals coincides with conflict of interest, leading to millions of unexplained HIV infections

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.

[1] World Medical Association. 2005. Declaration of Lisbon on the Rights of the Patient. Ferney-Voltaire, France: WMA. Available at: (accessed 18 August 2012).

[3] Gisselquist D, Rothenberg R, Potterat JJ, Drucker E. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. By: Int J STD AIDS 2002; 13: 657-666. Available at:

[5] Gisselquist D, Potterat JJ, Brody S, Vachon F, Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161. Available at:

[6] WHO. Unsafe injection practices and HIV Infection. Meeting summary (14 March 2003 meeting, undated summary posted by WHO later in 2003). Available at: (accessed 6 January 2013).

[7] WHO. Expert group stresses that unsafe sex is primary mode of transmission of HIV in Africa. Media Center statement 14 March 2003. Available at: (accessed 6 January 2013).

[8] WHO. Unsafe injection practices and HIV Infection. Meeting summary (14 March 2003 meeting, undated summary posted by WHO later in 2003). Available at: (accessed 6 January 2013).

UNAIDS Getting to Zero: Zero Lies, Zero Double Standards and Zero Institutional Racism

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?

WHO Acknowledges HIV Risk in Ugandan Hospitals?

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.

Maternal Health Care a Significant HIV Risk in Ethiopia

[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.]

Circumcision: a Case of Retributive Healthcare?

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

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because “there is no guarantee of the proper sterilization of such materials.” UN employees are also reassured that “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.”

The US Centers for Disease Control (CDC) states that “Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States.

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

  • 230,000 HIV Infections
  • 1,000,000 Hepatitis C Infections
  • 21,000,000 Hepatitis B Infections
  • The above resulting in 1,300,000 deaths each year (WHO figures)
  • Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
  • At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force ‘healthcare’ in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of ‘retributive healthcare’.

WHO’s and UNAIDS’ response: If there’s a problem, we warned Africans

On 15 October, three managers of dontgetstuck along with five other experts sent an Open Letter to the heads of WHO, UNAIDS, and World Bank, challenging them to warn and protect Africans from HIV through health care. There is no indication that Chan, Sidibe or Kim read the letter. The only response we have received is from De Lay of UNAIDS and Nakatani of WHO (see below).

The response, which falls short of what WHO and UNAIDS could do under the circumstances, leads to several questions:

Question 1: If the evidence we presented (16%-31% of HIV-positive children with HIV-negative mothers) had come from Europe, would WHO and UNAIDS let it go by without recommending urgent actions to correct whatever happened to infect children?

Even asking this question brings the realization that governments and populations in Europe would not wait to see what WHO or UNAIDS said about the situation – they would insist on investigations to find how children had been infected and thereby to ensure that their health care is safe. We can see such investigations in Russia under Gorbachev, Romania under Ceausescu, Libya under Kaddafi, Kazakhstan, Kyrgyzstan, and Uzbekistan – all of which countries acted without waiting for WHO advice or assistance.

Question 2: Since WHO and UNAIDS have not recommended a specific response to evidence of large numbers of HIV-positive African children with HIV-negative mothers, who if anyone is going to respond to protect African children?

De Lay and Nakatani say that WHO and UNAIDS have warned African governments about unsafe health care, in effect putting the onus on Africans to respond to the evidence in the Open Letter. Whether the onus belongs there or not, it seems clear that WHO and UNAIDS are not ready to do more to protect African children from unsafe health care. Will African governments step up, or will they take the low road, like WHO and UNAIDS, letting things go on and on?

[See also Simon Collery’s comments on WHO’s and UNAIDS’ reply, with information about health care conditions in Africa.]

WHO’s and UNAIDS’ letter responding to Open Letter

23 October 2012

Dear Dr Gisselquist and colleagues,

Thank you for the open letter sent to Mr Sidibe, Dr Chan and Dr Kim on 15 October, 2012. We recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission, and advise countries that an effective HIV response should take into account all available data on modes of transmission in the design and implementation of their response.

As part of our commitment to reducing HIV incidence and new HIV infections, both the World Health Organization (WHO) and UNAIDS have produced guidance with unsafe skin-piercing procedures. UNAIDS Prevention Policy Paper, and the WHO Global Health Sector Strategy on HIV/AIDS, 2011-2015 make explicit reference to the importance of preventing unsafe injections, surgical practices and blood transfusions. WHO and UNAIDS advise countries to scale up proven and cost-effective strategies, policies and programmes that are tailored to their actual HIV epidemic and its social, economic and health system context (Know Your Epidemic/Know Your Response).

Recently, WHO’s Director-General, Dr Margaret Chan called for action on injection safety. Since this call, a cross-departmental working group has been created to develop a policy document and implementation plan on the safety of all therapeutic injections.

Thank you for raising these issues in the letter and for your efforts in the fight against HIV.

Best regards,

Paul De Lay, Deputy Executive Director, Programme, UNAIDS
Dr Hiroki Nakatani, Assistant-Director General, HIV/AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases, WHO