Bloodborne HIV: Don't Get Stuck!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An interesting article appeared a few years ago in the African Journal of Political Science and International Relations about the African Diaspora, global learning and HIV/AIDS. The authors, Ngoyi K. Zacharie Bukonda and Tumba Ghislain Disashi, members of the African Diaspora themselves, are troubled by a number of things, not least the fact that they are not even given credit for their humanitarian work in Africa by Africans, let alone by non-Africans.

They carried out a program aiming to reduce HIV infection through unsafe medical practices in healthcare facilities in the Democratic Republic of Congo. They ran hundreds of training courses in infection control procedures and related issues, covering reduction of transmission of HIV, hepatitis and other blood borne diseases, quality improvement, and the like.

The authors note the patronizing attitude of non-Africans towards Africans in the HIV/AIDS field, where the dominant paradigm is of heterosexual transmission of the virus, with non-sexual transmission, such as through unsafe healthcare practices, almost entirely dismissed. This paradigm is even accepted and taught throughout African healthcare systems, despite substantial bodies of evidence that unsafe healthcare probably makes a significant contribution.

The paradigm is so pervasive that Africans, at home and abroad, view HIV/AIDS as a disease that results from promiscuous behavior, one that infects promiscuous people. The authors have not come across any other HIV/AIDS programs initiated by members of the African Diaspora that address this vital area of non-sexual (or vertical) HIV transmission.

A broader view of global learning is suggested on the basis of the authors’ experience of engaging their fellow Africans in this program, where things can be less formal and less geared towards specific qualifications. They feel that the part global learning could play in things like poverty reduction and HIV prevention and treatment have been neglected in standard definitions of the concept.

In addition, Africans of the Diaspora have not been accepted by the broader academic community as learners or as facilitators of global learning. They are not considered to have the capability or the inclination to mitigate epidemics such as HIV/AIDS, nor any other global problem, such as poverty. They do not even get recognition from Africans for what they have achieved and are depicted as disloyal and unpatriotic in the African press.

It is very disturbing that the view of the HIV industry towards Africans is not just that HIV is a disease spread by their own behavior, but also that Africans, even well educated Africans, are not capable of analysing HIV epidemics and allocating appropriate resources on the basis of differing circumstances that prevail among different African countries and within different parts of those countries.

United Press International’s health section has an article about the possibility that salons providing manicures, pedicures, shaving and other services may not be taking adequate precautions to avoid transmitting hepatitis to their clients. The report finds that “barbershop nail files, brushes, finger bowls, foot basins, buffers, razors, clippers and scissors may transmit hepatitis”. That’s no surprise here on the Don’t Get Stuck blog, but it’s not often you’ll find it mentioned in a health department report.

Hepatitis B or C may be transmitted through these reusable instruments unless they are properly cleaned and disinfected. A commentator concludes that “The risk of transmission of infectious disease, particularly hepatitis B and C, in personal care settings is significantly understudied in the United States [my emphasis].”

That’s all very well for the US and other Western countries, where disinfection procedures are more widely known and there are enforceable regulations in place. But in resource poor countries, such as Tanzania, Kenya and Uganda, manicures, pedicures and other cosmetic procedures often take place in the open air, in shops, homes and offices, and they are carried out by people with little or no training.

Not only are these risks not studied but they are considered to be negligible by those tasked with reducing transmission of HIV and other blood borne viruses. In the absence of any investigation whatsoever, it is concluded that almost all HIV transmission in African countries results from ‘unsafe’ heterosexual behavior. In addition to being incorrect, this is highly stigmatizing.

Risks faced in health facilities are also denied by UNAIDS, WHO and the like.  There’s an article on HealthLeaders Media site about cancer patients in a Nebraska, US clinic who are infected with hepatitis C because a nurse changed a needle when moving on to another patient, but reused the syringe. Some healthcare professionals seem to think that carries no risk of transmission, but they are wrong. Almost 100 patients were found to be infected after a thorough investigation, involving the recall of thousands of patients.

Despite the investigation, CDC (US Centers for Disease Control and Prevention) say this and other similar incidents are just the tip of the iceberg; the entire might of the US public health sector doesn’t appear to know the full extent of the problem. Instances of reused syringes, reused saline bags and other devices were recorded. But outside of these investigations, most of those infected by such incidents tend to be discovered by accident.

The risk of infection with hepatitis, HIV and other blood borne viruses from healthcare and cosmetic services may seem small, but it’s still a risk, especially in countries where prevalence of blood borne diseases is very high. There is no excuse for assuming that a very small percentage of these services are likely to transmit diseases and that, therefore, the majority of HIV infections are from unsafe sex.

People availing of the services and people providing the services need to be aware of the risks and what steps they take to can avoid them. Healthcare and cosmetic service transmission of blood borne diseases in African countries is in urgent need of investigation.