Bloodborne HIV: Don't Get Stuck!

A recent study indicates that use of injectable hormonal contraceptives, such as Depo Provera, may double transmission of HIV from HIV positive men to women receiving the injections and also from HIV positive women receiving the injections to HIV negative men with whom they have unprotected sex.

A family planning expert in Rwanda, Dr Thomas Nsengiyumva, finds the study to be misleading. He points out that one sexual partner must be HIV positive for this doubling of risk to occur, and they can reduce the risk considerably by using condoms.

This is true; no sexual contact between HIV negative couples gives rise to HIV transmission; and using condoms consistently and properly always reduces the risk of pregnancy and sexual transmission of HIV and other sexually transmitted infections.

Pathfinder International, who receive large amounts of funding (annual budget of over 100 million dollars) to promote family planning and reproductive health information and training in developing countries have also expressed their scepticism about the study. I agree with them that “premature speculation” can be dangerous. But this speculation doesn’t come from nowhere: it comes from the uncertainty that the HIV industry has created by not giving clear or convincing advice to users of the injectable drug.

If Pathfinder are really concerned about mother to child transmission of HIV, as they claim to be, there are far better ways of addressing that than by simply doling out various family planning commodities.

The HIV status of one or both partners in a relationship may not be known, or it may change without one or either partners being aware. So, in partnerships where one partner is known or suspected to be infected with HIV, or who may become infected, would it not be better for the female partner using injectable hormonal contraceptives to give up doing so and to rely on condoms, or some other method or combination of methods?

Findings about hormonal contraceptive drugs going back many years, decades even, show that they are questionable, that they have other risks besides HIV transmission. The most recent findings seem more like another nail in the coffin for such methods, at least until their safety has been assured. Injectable Depo Provera and similar drugs have not been shown to be safe.

Would people in Western countries accept the ‘reassurances’ of WHO that women should continue using Depo Provera until they have had time to discuss the issues? I think the advice to people would be immediate, however lengthy the discussions need to be. But, as it happens, most people in Western countries don’t use injectable hormonal contraceptives, unless they are poor or of African descent, or both, as is often the case.

The ‘dilemma’ seems to be: stop using the drug and risk unplanned pregnancy OR continue using the drug and risk unplanned pregnancy AND HIV transmission? Condoms and other methods are available, effective and cheap and can be used on their own or in combination, with reference to the specific needs of each user. Is that really such a dilemma?

The HIV industry constantly implies that everyone in high prevalence countries in Africa is at risk of being infected with HIV and that no one knows what their partner is up to. Therefore, anyone on Depo Provera or similar needs to understand the additional risk that the injectable version of the drug adds to their existing high level of risk.

If I was in a relationship with someone taking the injectable drug, or if I was taking it myself, I would not be waiting till January, till the World Health Organization decides “if evidence is now strong enough to advise women that the method may increase their risk of getting or transmitting HIV”. I’d find another contraceptive method, at least temporarily. People need clear and convincing advice. Why should they wait?

The New York Times reviews Dr Jacques Pepin’s ‘The Origins of Aids’, which aims to shed light on how rapidly expanding twentieth century public health campaigns may have been responsible for the spread of HIV and other blood-borne diseases in French and Belgian colonies from the 1920s onwards. Patients on such programs could get up to 300 injections in a lifetime. As a precedent, a schistosomiasis (bilharzia) campaign in Egypt that ended in 1980 infected more than half the recipients with hepatitis C, which is still more widespread in Egypt than in any other country in the world.

The book, ‘The Origins of AIDS’, is by Dr Jacques Pepin, whose papers on the subject have been discussed on my HIV in Kenya blog in the past. Starting 60 years before the disease was even noticed, the book aims to tie up some of the many mysteries about how a disease that is now said to be almost always transmitted sexually could have spread to become a pandemic, infecting over 20 million people in a handful of sub-Saharan African and another 15 million people throughout the rest of the world. 25 million are estimated to have died from AIDS.

The author himself admits that he may have inadvertently infected some of his patients because the process of ensuring that injecting equipment was sterile was often lacking. He was working on a schistosomiasis epidemic in the early 1980s, before HIV had been recognized. But it was when Pepin went on to work with HIV-2, HIV-1 being the more widespread and more deadly of the two, that the question of how a virus that was difficult to transmit sexually could become a (partly) sexually transmitted pandemic.

People with HIV-2 can live for a long time and it was only found in older people at the time he started working with it in Guinea-Bissau. This suggested that it was dying out, as it was not spreading among young, sexually active people. So Pepin sought an alternative mode of transmission that allowed HIV-2 to have once flourished, and then die out. He began to investigate various public health campaigns against syphilis, yaws, leprosy, TB and others, which went on until the 1960s. Notice, some of the groups targeted by such campaigns would have overlapped with those currently targeted by HIV campaigns, being sexually transmitted.

Pepin looked for evidence that blood-borne diseases other than HIV had been spread by injections, circumcisions and other skin breaking practices. He also noted the colonial public health programs’ keen interest in sex workers and various other practices that may relate to sexual behavior. But when the virus jumped from chimps to hunters, the whole process consisted of such low probability events that sexual transmission alone would never have allowed HIV to become a pandemic; it would have just died out, having only infected a handful of people.

This is where Pepin’s notion of an ‘amplifier’ comes in. He found that blood transmission of HIV is 10 times more efficient than sexual transmission. But the amplifier in colonial African countries was the public health campaigns, with their heavy use of injections. It was only later, once public health campaigns had spread the virus throughout many populations, that sexual behavior became responsible for further transmission.

Interestingly, Pepin says that sexually transmitted infection (STI) eradication campaigns ceased some time before the contribution of sexual transmission to the HIV epidemic increased. But in the Nairobi instance cited, where HIV prevalence went from 5% to 82% in three years, it seems possible that an STI eradication campaign may have played a part in spreading HIV among sex workers, rather than sexual behavior alone explaining the massive prevalence rate recorded in the mid 1980s. After all, HIV prevalence among sex workers, along with other STI rates, declined sharply after about 1986, and the downward trend continued well into the 1990s.

Again, when HIV spread to Haiti, Pepin notes that the virus was unlikely to have been spread very widely through sex alone. This time, he suggests as an amplifier a plasma donation center, which operated in the early 1970s. The process involves donating blood from which the plasma is extracted and the remainder is injected back into the donor. If unsterile equipment was reused this would risk spreading HIV and other blood-borne diseases. This route of HIV transmission has been well demonstrated in other countries and may still occur.

These blood products were exported to the US. Haiti was also well known as a sex-tourism destination, especially for gay sex, so this would have played a part. Anal sex, whether male to male or male to female, is a far more efficient transmitter of HIV than penile-vaginal sex. And thus, the earliest discovered victims of HIV and AIDS were men who had sex with men and hemophiliacs. The former are still at higher risk than those who don’t engage in anal sex; the latter are still at risk in countries where the safety of healthcare can not be guaranteed, such as all the medium and high prevalence countries in Africa.

Let us hope that the work that Pepin has started will prompt an investigation into the possibility that unsafe healthcare may still be responsible for HIV transmission in some resource-poor areas. Efforts to influence people’s sexual behavior, which go back many decades, starting with efforts to reduce STI rates and birth rates and continuing right up to the present, have had few successes, if any. But investigating the many cases of HIV infection where sexual contact is unlikely to have been responsible, or unlikely to have occurred, could present a far more effective, and less stigmatizing way of reducing HIV transmission.

[I have used this NY Times review to relate Dr Pepin’s research to other research into the relative contribution of non-sexually transmitted HIV to the current pandemic. Since writing the above, I have had the opportunity to read The Origins of Aids and have made some comments on the HIV in Kenya blog (hivinkenya.blogspot.com); more should follow once I’ve had time to read some of his sources.]

Although it is written in a somewhat anecdotal style, a recent article by Moses Okinyi raises some important points. Estimates of the relative contribution of unsafe medical injections to HIV epidemics in African countries range from the improbably low of less than 1% to the frighteningly high 25%. But what is most shocking is that there are only estimates, based on far too little data. This is an unacceptable situation thirty years into the HIV pandemic.

Okinyi notes the use of figures for HIV infections in children who have HIV negative mothers to build up some idea of the size of the problem. But many may be horrified just to hear that there are sizable numbers of HIV positive children with HIV negative mothers, the children’s HIV positive status often not being identified until years after they were infected because their mother happened to test negative.

The recently released film, Puncture, touches on some of the issues. A nurse is infected with HIV through a needlestick injury when working with a HIV positive patient. Things get interesting when the ensuing investigation reveals that there are syringes available that reduce the chances of such an injury and eliminate reuse of the device. Yet rivalry between producers of medical devices meant that the hospital was still using disposable syringes which carry a risk to the healthcare workers, and can also be reused.

Of course, the fact that syringes can be reused doesn’t mean that they are reused. But in countries where HIV prevalence is high and resources are scarce, it could be a temptation, even a necessity. Several Service Provision Assessment Reports have shown that many health facilities don’t have the equipment, supplies, procedures, even the training they need to prevent infection in healthcare settings.

The movie apparently (I haven’t seen it) takes an adversarial approach to the issue. This is unlikely to be helpful in developing countries, where eliminating such infections is the most important step, rather than pointing fingers at those thought to be ‘to blame’. There has been too much finger pointing already and it has been counterproductive.

However, people in high prevalence countries need to know how to avoid being infected with HIV and other blood borne diseases in healthcare and other settings, how to avoid transmitting these diseases and generally ensuring that the healthcare they and their family and friends receive is safe.

In addition to avoiding infection, recognition that HIV is not always transmitted sexually should reduce the stigma which has built up around a disease that is said by UNAIDS and the HIV industry to be 80-90% transmitted by unsafe heterosexual sex. In fact, the industry doesn’t really know the extent of non-sexual HIV transmission, despite their glib assurances.

Okinyi mentions a young HIV postive boy in Kenya who was probably infected through contaminated injecting equipment, or some other medical device. The boy’s mother is still HIV negative, though she would have risked being infected by her child through breastfeeding. It was only when the boy was diagnosed with TB that he was even tested for HIV. If his mother had been tested then and been found to be positive, it is likely that the whole issue of hospital transmitted HIV would never have been raised.

A lot of effort has been made to replace reusable syringes in resource poor countries but there is still a long way to go. And it’s not in the interest of those producing reusable (though nominally disposable) injecting equipment to advocate the use of something that is made by a competitor. Producers of medical devices, like pharmaceutical companies, make good use of their ability to influence what products doctors and other practitioners use most. Patient safety is only going to be a concern to them if it guarantees they increase their profits. If it cuts into their profits, they might prefer the issues to remain ignored (or strongly denied, as they are by UNAIDS).

Using estimates of HIV inefections in infants and young children tends to rule out the possiblity that they were infected sexually. Whereas, if any HIV positive person in high prevalence African countries is, or could be sexually active, it is generally assumed that they were infected sexually, regardless of the low levels of sexual risk they may have faced, or the high levels of non-sexual risk.

Whatever technologies may be available, ultimately the problems of hospital acquired and hospital transmitted HIV will continue until they are recognized as problems, rather than strenuously denied. This requires thorough investigation of conditions and practices in health facilities, with honest disclosure of findings. It will then be possible to estimate the relative contributions of sexual and non-sexual modes of transmission, and implement HIV prevention programs accordingly.

Allowing unsafe healthcare practices to continue, uninvestigated, would not be acceptable in Western countries. Nor would the use of substandard equipment and supplies that are known to increase risk to patients, healthcare workers and even the environment. So why are they acceptable to Western donors, who often contribute to such phenomena through providing the health aid money, and also deciding how it should be spent?

All the humming and hawing about injectable hormonal contraceptive, Depo Provera, must be very confusing to people who want to know whether they should discontinue using it, continue using it or get advice from a health professional. However, USAID have weighed in with the clear advice to continue using it.

Their brief communication concludes that “USAID does not believe that a change in contraceptive policy or programming is appropriate or necessary at this time”. I find this advice surprising. People who have the combined problem of avoiding conception and protecting themselves against sexually transmitted infections (STI) can always use a different contraceptive method (such as condoms), or combination of methods.

Therefore, people with the luxury of good advice and a wide range of contraceptive methods at their disposal should avail of those. But what about all the people to whom these are not available? They are the most likely to be using Depo Provera, as it is most frequently used by members of ethnic minorities in rich countries and by the general population if poor countries.

The worry is not just about HIV, that’s only one disease. But there have been known side effects relating to the use of Depo Provera since the 1990s. Concerns have even been raised about the use of the drug it contains far earlier than that. If Depo Provera is not generally used by middle class white people in rich countries, why is it still being promoted to non-white people in poor countries, given the long standing and serious concerns about its safety?

Someone has sent me rough calculations on how effective stopping the use of Depo Provera would be in reducing the risk of HIV transmission, compared to UNAIDS’ beloved male circumcision. Circumcising men only reduces the risk of women transmitting HIV to men by quite a small factor. But it substantially increases the risk of men transmitting HIV to women. On the other hand, stopping Depo Provera use reduces the risk of transmitting from men to women and from women to men.

As mentioned above, there are more health issues here than HIV, or even STIs or unplanned pregnancies. So why promote one HIV ‘prevention’ method that will almost certainly increase transmission to women (male circumcision), without reducing transmission to men that much, while also promoting a contraceptive method that increases transmission in both directions (Depo Provera, and perhaps other hormonal contraceptives)?

In developing countries there is also the issue of unsafe healthcare, the as yet unaddressed problem of reused injecting equipment. This may or may not be a factor in the association between injectable Depo Provera use and increased HIV transmission risk. As there have been no investigations of possible transmission of HIV or other blood-borne diseases in Africa through unsafe healthcare, perhaps USAID will also clarify this matter while they are considering Depo Provera (if they are still considering Depo Provera).

“Man who donated HIV tainted blood jailed“, says a headline on asiaone health website. According to the article, the man “failed to declare on his donor health assessment form that he had recently slept with prostitutes”. The discovery was made after the man donated blood in November 2009. He had previously donated blood between July 2008 and August 2009 and was HIV negative. But his alleged unprotected sex with sex workers was said to have taken place in December 2007, so that particular event was not responsible for his change of status.

Anyhow, the false declarations he is said to have made were for earlier donations, not the one found to be contaminated. But the blood transfusion service would do well to investigate its own services. Because, if the man in question did not have any further possible sexual exposures to HIV after the one in 2007, he might have been infected through the use of contaminated equipment by the transfusion services. This phenomenon has been common in the past in China and is still likely to be a considerable risk.

According to a statement from the Health Science Authority, it “takes its responsibility to safeguard the national blood supply very seriously”. Therefore, they might also like to taken into account the very low prevalence of HIV among Chinese sex workers (the incident was said to have involved Chinese sex workers), estimated to be about 0.6% (which is the same as national prevalence for the US). Indeed, a number of countries have found that sex workers are not very likely to be HIV positive unless they also face non-sexual risks, such as intravenous drug use. A true assessment of risk for HIV and other blood borne viruses can not be made without taking into account both sexual and non-sexual risks.

Why do so many HIV-positive children in Africa have HIV-negative mothers? For example, approximately 30% of HIV-positive kids aged 0-11 years have HIV-negative mothers in Mozambique (see pp. 177-181 in: http://www.measuredhs.com/pubs/pdf/AIS8/AIS8.pdf).

Why are so many virgin men and women found with HIV? In the Republic of Congo, for example, virgin women aged 15-49 years have higher HIV prevalence than all women, 4.2% vs 4.1% (see p. 101 in: http://www.measuredhs.com/pubs/pdf/AIS7/AIS7.pdf).

The personal stories behind these statistics are hard to fit with the common view that almost all infections are from sex. Why has there been so little attention and response to Africans with unexplained infections?

THE PURPOSE OF THIS NOTE IS TO INITIATE DEBATE ABOUT WHETHER TO CONTINUE TO IGNORE NON-SEXUAL HIV INFECTIONS IN AFRICA. To do so, this note presents four arguments for AIDS activists, both in Africa and elsewhere, to recognize and respond to HIV from skin-piercing procedures in African health care and cosmetic services.

1. DE-STIGMATIZING HIV/AIDS: Programs for HIV prevention in Africa – including especially foreign-funded programs — focus almost exclusively on sex. With all attention on sex, the emotions, prejudices, and controversies around sex naturally spill over into HIV programs. Thus, it is not only wrong to think that all African HIV comes from sex (see points 3 and 4, below), but also confusing and distracting. Currently, stigma against HIV is so great that most people with unexplained infections keep silent, so as not to be accused of sexual behaviors that some people don’t like. When the public discourse is corrected to recognize blood-borne as well as sexual HIV (see: https://dontgetstuck.wordpress.com), people with HIV from blood risks will be able to speak out without facing stigma compounded by charges they are lying. And they will then be able to contribute to public efforts to make health care and cosmetic services safe.

2. PREVENTING HIV INFECTIONS: Ensuring that medical facilities are safe will not only prevent HIV infection but also the transmission of other blood borne pathogens. Across Africa, HIV prevalence is lower in countries where more people are aware of blood-borne risks for HIV; see: https://dontgetstuck.wordpress.com/africans-aware-of/

3. SEX ALONE CAN’T EXPLAIN AFRICA’s HIV EPIDEMICS: All attempts to explain Africa’s epidemics as exclusively sexual have failed to find anything that is so different about sex in Africa that could account for Africa’s high rates of HIV prevalence. Studies find that Africans have fewer partners and use condoms more than Americans and Europeans.

Circumcision is less common in Europe than Africa. Sex can’t explain how HIV prevalence is lower after long term wars, and among people living further from health clinics. Sex is a risk for HIV because so many Africans are infected – but how are so many infected?  

4. EVIDENCE THAT AFRICANS GET HIV FROM SKIN-PIERCING EVENTS: A lot of evidence shows HIV transmission through skin-piercing procedures in Africa. Evidence is both old and new. For example:

(a) In 1985, Project SIDA in Kinshasa, Zaire (now the Democratic Republic of Congo), tested inpatient and outpatient children aged 1-24 months and their mothers for HIV. Seventeen (39%) of 44 HIV-positive children had HIV-negative mothers. Among children with HIV-negative mothers, “medical injections seemed to be the most important risk factor for HIV…” The study team noted, “Injections are often administered in dispensaries which reuse needles and syringes yet may not adequately sterilize them” (Mann et al, Risk factors for human immunodeficiency virus seropositivity among children 1-24 months old in Kinshasa, Zaire. Lancet 1986, ii: 654-7. p. 656.)

(b) Around 1990, WHO’s Global Programme on AIDS coordinated a study in Rwanda, Uganda, Tanzania, and Zambia to test in-patient children 6-59 months old and their mothers for HIV. Sixty-one (1.1%) of 5,593 children were HIV-positive with HIV-negative mothers; only three had been transfused. WHO experts concluded “the risk of non-perinatally acquired HIV and of patient-to-patient transmission of HIV among children in health care settings is low” (Global Programme on AIDS. 1992-1993 Progress Report. Geneva: WHO, 1993). A similar conclusion would be unthinkable if 1% of inpatient children in London, Boston, or Seoul were found with non-vertical HIV infections.

(c) A study among women in Malawi, 2003-05, found that women who had received hormone injections for birth control were 10.4 times more likely than other women to return with incident HIV infections, and 23 of 27 women with incident infections had received such injections; relative risk was adjusted for age, bacterial vaginosis, and number of sexual partners; reported condom use was uncommon for both women who acquired HIV infection (11.5%) as well as for those who remained HIV-negative (15.1%) (Kumwenda et al. Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi. Clin Infect Dis 2008; 46: 1913-1920).

(d) Many other studies in Africa link incident HIV to injections, report virgins with HIV, and report kids with HIV but HIV-negative mothers (see Chapters 7, 8, and 9 of Points to Consider, available for free download at: http://sites.google.com/site/davidgisselquist/pointstoconsider).

PROPOSAL: Let’s dialogue about this at these websites – http://aidsperspective.net/blog/, http://hivinkenya.blogspot.com/, http://blogs.poz.com/sean/, https://dontgetstuck.wordpress.com/ http://signpostonline.info/ – about the evidence, what to do, anything else relevant to the issue. 

Simon Collery, David Gisselquist

The Florida Courier is far more blunt than other articles about the Depo Provera hormonal contraceptive drug that has been found to increase transmission of HIV from men to women and from women to men. Noting that the use of Depo has long been opposed by Black, Latina and Native American women’s health groups, it is apparent that the drug is disproportionately used by black and poor women, even though it was known there were serious side effects associated with its use.

For many years the drug has been actively promoted, in both its injectable and oral forms, in African countries. In the US, users are “33 percent under the age of 19, 84 percent Black women, and 74 percent low income”. Manufacturer Pfizer has acknowledged some of the side effects. But tens of millions of units of the drug have been supplied to developing countries, especially Mozambique, Tanzania and Nigeria.

While Pfizer claimed not have read the report some time after it had been published, and so refused to comment on it, the development community has been slow to issue guidelines on use of Depo Provera pills and injections. And none of the mainstream media appear to have mentioned the fact that injectable contraceptives may be administered using reused and unsterile equipment, or may have been so administered in the past.

Guidance is anxiously awaited by those who don’t wish to stop using birth control but must avoid any serious side effects that may result from Depo Provera.

Dr Devon Brewer has just published a paper on the role of scarification and male circumcision in transmitting HIV in Mozambican children and youth. The findings suggest that there is little difference in transmission whether the circumcision is performed by a traditional circumciser or a medically qualified professional. This may help shed light on the question of why “16-20% of HIV infected children had seronegative mothers” in surveys carried out in Swaziland and Uganda.

HIV transmission is not particularly closely correlated with sexual behavior in African countries but many children infected with HIV are not even sexually active (nor are quite a number of adolescents and adults). Considering the current popularity of mass male circumcision as a means of reducing HIV, and the millions of dollars being thrown at it, these findings deserve to be investigated, not just dismissed by UNAIDS and the HIV industry in general.

Scarification may be common in some countries, including countries with high prevalence of HIV and other blood borne diseases. So far, little research has been carried out into the possible contribution of scarification to HIV epidemics.

Brewer finds that “circumcised and scarified children and youth were two to three times more likely to be infected with HIV than children and youth who had not been circumcised or scarified, respectively”. He further remarks that these phenomena could only account for a relatively small fraction of horizontally acquired HIV infections in these groups. Therefore, other blood exposures, such as unsafe healthcare, probably account for the rest.

While standards of hygiene may be higher in clinical settings than in traditional settings, medical circumcision may involve more risky procedures, such as anesthetic injections and suturing. Also, health facilities may have a tendency to concentrate blood-borne and other pathogens, given that people who are sick attend these facilities, if possible.

There is plenty of research showing that medical facilities in African countries are ill-equipped to control infections that are spread as a result of medical procedures. Kenya, Uganda, Tanzania and other countries already carrying out mass male circumcision campaigns, along with those planning to do so, would do well to ensure that they don’t risk doing more harm than good.

It would have been preferable to carry out a thorough investigation before rolling out such campaigns because it’s difficult to interrupt something that has already gone so far and attracted and spent so much money. Perhaps this finding about male circumcision could be compared to the even longer running and far more widespread contraception campaigns, which may also have exposed people to risks of HIV transmission.

As Brewer concludes, “To determine modes of HIV transmission with confidence, researchers must employ more rigorous research designs than have been used to date in sub-Saharan Africa. Such designs involve assessing blood and sexual exposures comprehensively in incident HIV cases and controls, tracing their contacts corresponding to these exposures, and sequencing infected person’s HIV isolates. In the meantime, Mozambicans and other Africans should be warned about all risks of blood-borne HIV transmission, including scarification and medical and traditional circumcision, and informed about how these risks can be avoided”.

All the mainstream media have been running the story about recent research which shows that hormonal contraception commonly used in African countries substantially increases the risk of HIV infection, for both women and men.

There is now an urgent need to give people advice that will protect them from harm, while also offering them the most effective and acceptable forms of birth control, without risking infection with sexually transmitted infections (STI).

Something that is not mentioned by the copious media articles on the issue is that, because the most popular means of administering hormonal contraception in African countries is by injection, this may point to an additional factor in the rapid spread of HIV; injection safety may have improved in the last ten years or so, but during periods when HIV transmission rates were highest, it is possible that injecting equipment was used in ways that did not protect against HIV transmission.

Sexual and reproductive health programs have had a poor record in emphasizing the dual use of family planning methods, for preventing unplanned pregnancies and for protecting against STIs. The programs may not have adequately convinced people of the need for protection against STIs.

After all, many of the people who have been infected with HIV would not consider themselves to be particularly promiscuous or careless, and rightly so. The majority of people infected in countries such as Kenya, Tanzania and Uganda were not at high risk on account of their sexual behavior.

The thrust of this blog and website is to emphasize that HIV can be transmitted through unsafe sex and through unsafe healthcare and cosmetic services. The need to investigate the role of unsafe injections in the administration of hormonal contraceptives is as urgent as that of the role of these contraceptives in increasing HIV transmission.

The manufacturer of a popular version of injectible contraceptive, Depo-Provera, is Pfizer. Instead of declining to comment on the grounds that they haven’t read the study (it’s not that long) they could break new ground in HIV prevention by leading the investigation.

One commentator suggested greater use of “intrauterine devices, implants and other methods” on the grounds that if use of injectible contraception is to decrease, there needs to be a viable alternative. But some of these methods may also carry HIV transmission risks, something that should be explored thoroughly by those thinking of changing contraception method.

You might expect research into prevention of non-sexually transmitted HIV to start with the available literature. But when the research is carried out by Bjorn Lomborg’s RethinkHIV, you’d be mistaken. They have already produced three papers that ignore entirely the substantial literature which shows that non-sexually transmitted HIV, especially that transmitted through unsafe healthcare and cosmetic services, could be very high in many African countries.

The RethinkHIV researchers do list a few authors who dismiss non-sexual HIV transmission or claim that it is insignificant. But they don’t mention the research which recommends that non-sexual modes of transmission are in serious need of investigation. Adequate investigation into the relative role of non-sexual HIV transmission modes in the worst epidemics in the world has never been carried out; and funders and research institutions seem uninterested in addressing these and related issues.

However, out of the three papers published by RethinkHIV, one concludes that not enough is known about non-sexually transmitted HIV to evaluate prevention strategies in terms of cost, benefit, effectiveness, acceptability or anything else. Without alluding to the wealth of research already available, the short paper by Rob Baltussen and Jan Hontelez dismiss the rather lengthy claims made by Lori Bollinger in another paper as being without foundation.

Bollinger looked at issues such as autodisable syringes (ones that automatically break after one use and so can’t be reused), healthcare staff training in the proper use of syringes, safe disposal of medical waste and information for the public about non-sexual HIV transmission. The problem with her economic evaluation of these is that she availed of UNAIDS’ data on the different modes of transmission, which is woefully inadequate, being based more on assumption and guesswork than genuine research.

Baltussen and Hontelez’s questioning of UNAIDS’ data is brief and devastating and should be read by everyone interested in questioning the absense of funding for HIV prevention strategies that address non-sexual modes of transmission. It will be interesting to see whether this (inadvertently?) adversarial approach to what could be the biggest contributors to HIV transmission in African countries pays off.

This site provides information about non-sexually transmitted HIV and there are also links to various other related resources available on the web. In addition, you will find links to papers and sources of data used to create the site, throughout.

[I have have also covered these issues on my HIV in Kenya blog.]