Bloodborne HIV: Don't Get Stuck!

Continuing the theme of my last post, but this time using the 2011 National Antenatal Sentinel HIV & Syphilis Prevalence Survey in South Africa, I again wonder why authors of such reports insist that HIV is almost always transmitted through ‘unsafe’ sexual behavior and fail to say anything about non-sexual modes of transmission.

Disturbingly, the authors note that the “the 2011 report has shown beyond reasonable doubt that there is no significant correlation between HIV and Treponema palladium, the etiological agent for active syphilis, as co-factor for HIV infection.In the 2012 survey we have started to pilot monitoring of Herpes type 2, HHV2, which usually causes genital herpes and is transmitted primarily by direct contact with sores, most often during sexual contact.” This sentiment is echoed on three further occasions in the document.

Rather than suspecting that HIV may sometimes be transmitted through non-sexual routes, such as unsafe healthcare, unsafe cosmetic practices or unsafe traditional practices, they are looking for another sexually transmitted infection to ‘correlate’ with HIV. Why? Or, better still, why not investigate non-sexual routes? There’s plenty of evidence.

South Africa is not the only country to survey syphilis prevalence along with HIV prevalence. Uganda and Zambia also do so, with similar results. Below are radar graphs for all three countries, showing that if syphilis is a proxy for unsafe sexual behavior, HIV does not resemble syphilis very much. This is no surprise, but data continues to be collected and analyzed, before concluding that there is little or no correlation.

HIV and Syphilis in South Africa

HIV and Syphilis in Uganda

HIV and Syphilis in Zambia

How many more years are to be wasted pretending that HIV is almost always transmitted through sexual behavior in high HIV prevalence African countries, but nowhere else? People in high HIV prevalence countries need to be made aware of the non-sexual risks they face. Health facilities, cosmetic facilities and other sites where HIV may be transmitted through contaminated blood or other bodily fluids also need to be made safer. Failing to address lack of knowledge and unsafe non-sexual practices results in an as yet unestimated number of people becoming infected with HIV; these infections are all avoidable.

The latest South African National HIV Prevalence, Incidence and Behaviour Survey, 2012 was released recently. Much of the media coverage concentrated on things like the worrying increase in HIV prevalence compared to the last survey, which was carried out in 2008, said to be the combined result of new infections and a big increase in the number of people living longer with HIV as a result of being on antiretroviral therapy.

The report is a useful document, as far as it goes. But there isn’t even a hint that several non-sexual modes of HIV transmission could be contributing to the worst HIV epidemic in the world (in terms of number of people living with HIV, 6.4 million). This is a lot more worrying than the increase in prevalence, because failing to address non-sexual modes of transmission will result in people continuing to be infected through unsafe healthcare, unsafe cosmetic practices and unsafe traditional practices.

Underlining the clear assumption that almost all HIV transmission is a result of unsafe sexual behavior, there is a lot of attention paid to mass male circumcision programs. These are not going so well in South Africa because the majority of circumcised people chose this as a tribal rite, not because they had been hoodwinked into believing that it would save them from various diseases, HIV just being one of them. But the report fails to stress that this means most circumcised males in South Africa faced a far higher risk of being infected with a number of diseases by being circumcised in unsterile conditions.

The report also agonizes over the usual ‘behavioral determinants of HIV’, such as early sexual debut (a minority of males and females become sexually active at a young age, the vast majority don’t), ‘intergenerational’ sex (a minority, about a fifth of females do, most males don’t and this issue has been questioned recently), multiple sexual partners (also a minority do this, more males than females, although HIV prevalence is far higher among females) and condom use (increasing, but probably too low to have much impact on transmission).

However, simply ignoring the possible significance of how people respond to questions is the most arrogant, and probably the most dangerous aspect of the report. There is a list of reasons people gave for believing they would not contract HIV and a few from this list were cited in the media, triumphantly, because some people who thought they would not contract the virus were already infected. Here’s the list, with the number of people giving the response and the percentage:

Reasons for belief one would not contract HIV – number and % of cases

I have never had sex before 21,150, 11.0
I abstain from sex 21,147, 21.3
I am faithful to my partner 21,144, 32.0
I trust my partner 21,149, 22.5
I use condoms 21,146, 19.2
I know my HIV status 21,136, 9.8
I know the status of my partner 21,134, 4.4
I do not have sex with sex workers/prostitutes 21,112, 1.7
My ancestors protect me 21,070, 1.1
God protects me 21,142, 2.5
I am not at risk for HIV 21,151, 8.9
Other 21,142, 10.4

Do those carrying out the survey never, for one moment, suspect that some people might be telling the truth? Some people who have never had sex before are being told for the first time that they are HIV positive, and that it’s almost certain they were infected through some kind of unsafe sex. What efforts are made to find out how they were infected? What about those who are faithful to their partner? Is their partner tested?

The authors of the report seem to relish the term ‘evidence-based’ when referring to various different ‘interventions’ that are expected to reduce HIV transmission; when these interventions appear to fail, those who become infected, or who give inconvenient answers to survey questions, are blamed for their ‘sexual behavior’. If the researchers don’t even check how people become infected, in what way are the interventions evidence-based? If people are not believed when the answers don’t suit the researchers, why should we accept other parts of the report where the answers are in line with what the researchers expect to hear?

Assuming that HIV is almost always transmitted through ‘unsafe’ sexual behavior, regardless of all the indications that it is also transmitted through unsafe healthcare, cosmetic or traditional practices, is a betrayal of HIV positive people; it is also a betrayal of those who still risk becoming infected through such routes. These non-sexual routes urgently need to be addressed by investigating and cleaning up health centers, salons and other potential locations, and by warning patients about the dangers of being exposed to the blood and bodily fluids of other people.

A recent newspaper article on Burundi refers to the country’s failure to achieve a Millennium Development Goal (MDG) to get “HIV prevalence to zero by 2015”. This is not an MDG and is a confusion with one of UNAIDS’ slogans, which goes ‘zero new infections, zero AIDS-related deaths and zero discrimination’.

The journalist continues “One of the reasons for this [failure] is an unequal access to quality healthcare and prevention services for high-risk groups in Burundi.” One of the consequences of UNAIDS’ insistance that HIV is almost always transmitted through ‘unsafe’ sexual behavior in African countries (but not in non-African countries) is that no one in high prevalence countries wants to be associated with efforts to reduce transmission amongst those who seem to be most likely to be infected and to infect others.

Sex education in schools is almost non-existant, or it’s provided by religious groups whose aim can be to misinform rather than enlighten; sex work is illegal in many African countries; male to male sex is illegal and carries risks that go beyond HIV; harm reduction programs to reduce transmission among intravenous drug users by supplying them with safe injection equipment and other facilities is a political hot potato, with many donors actively discouraging it because it ‘encourages drug use’, etc.

But quality healthcare is denied to the majority of Burundians, not just those who fall into one of UNAIDS’ numerous ‘most at risk’ groups. Indeed, those who have had the best access to healthcare may also be more likely to be HIV positive – urban dwelling, wealthy people with higher levels of education.

Burundi is a very poor country, with the lowest expenditure on health in East Africa, but also the lowest HIV prevalence. At 1.4%, prevalence is only a fraction of that of Swaziland, where the majority of poor, rural dwelling, poorly educated women give birth with the assistance of a skilled healthcare worker. Only around 30% of Burundians from similar backgrounds do so.

The article gives the impression that poverty in some way causes HIV and sex work, because poor people have no option but to have sex for money or food or other benefits, as if poverty were something quite neutral in the absence of HIV and sex work. But poverty may also increase HIV transmission by exposing people to unsafe healthcare, or to the absence of healthcare.

If unsafe healthcare is the only option, people may risk infection with very serious illnesses in health facilities. Yet avoiding them altogether means they risk many other serious illnesses. Those engaging in sex work face terrible occupational risk, but if healthcare facilities are also unsafe, their non-sexual risk for HIV and other diseases may also be increased.

No one working in development would argue that poverty is unimportant, but it doesn’t play exactly the role in HIV transmission claimed by UNAIDS and the HIV industry in general. Poverty denies people access to healthcare altogether, or it condemns them to risking unsafe healthcare. So poverty reduction and greater access to healthcare needs to mean safe healthcare, otherwise access to healthcare and poverty reduction may be dangerously counterproductive.

In 2007 the Population Council published an article on early marriage and HIV in Kenya. There’s nothing surprising about a eugenicist or ‘population’ NGO taking a close interest in such matters, of course, and the Population Reference Bureau published an article about cross-generational sex in various Africa countries in the same year. Both articles express concern about these phenomena potentially posing a risk for HIV transmission.

What is surprising is the figures used by the Population Council, listed below. The province where early marriage is most common, Northeastern, is the province where HIV prevalence is lowest, by a long shot. Early marriage is also less common in Nairobi, where HIV prevalence is second highest in the country. Where HIV prevalence is highest, Nyanza, early marriage is not particularly common. At least, there is no noticeable correlation between the phenomenon and HIV prevalence.

* The relevant table is 14.5, page 217

In fact, these NGOs should have been very suspicious. HIV prevalence often tends to be higher among wealthier, better educated, urban dwelling, employed people, whereas intergenerational sex and marriage may be more closely associated with poorer, less well educated, rural dwelling, unemployed people.

So it is significant that AidsMap reported a presentation at the 21st Conference on Retroviruses and Opportunistic Infections (CROI). This presentation suggests that “Sex with older men is not placing women under 30 at higher risk of HIV infection in rural South Africa, and relationships with older men may even be protecting women over 30 from infection“.

The author of the study suggests that programs addressing relationships between older men and younger women may even stigmatize men and women in such relationships. But stigmatizing people with, or thought to be at risk of, HIV is something NGOs and international health institutions have never shied away from.

The media will be disappointed because they have enjoyed years of talking about sugar daddies and sugar mummies, which fits into the ‘all men are bastards, all women are victims’ paradigm of HIV transmission, and their concomitant assumptions that African men will do anything for sex and African women will do anything for money.

Many population (and eugenicist) NGOs generally also claim an interest in ‘reproductive health’, but their agenda often seems to veer towards matters that have little to do with health, and activities that have little to do with human rights. But for those that really are interested in health, there is another set of figures they may be interested in.

The Service Provision Assessment for Kenya for 2010 (Table 6.7, page 136) finds that only 25% of health facilities in Nyanza Province have essential supplies for common complications relating to child delivery, which means 75% of facilities lack “Needle and syringes, intravenous solution with infusion set, injectable oxytocic, and suture material and needle holder all located in delivery room area; oral antibiotic (cotrimoxazole or amoxicillin) located in pharmacy or delivery room area”.

With the highest HIV prevalence in Kenya, the fact that 46% of hospitals in Nyanza do not have all essential supplies for delivery, which refers to “Scissors or blade, cord clamp, suction apparatus, antibiotic eye ointment for newborn, skin disinfectant”, the Population Council and Population Reference Bureau may like to take a look at unsafe healthcare, now that intergenerational sex and marriage seem so much less of a priority now.

Again, these NGOs should also have noticed something important about HIV prevalence often being more closely associated with wealthier, better educated, employed, urban dwelling people: access to health facilities is also generally far higher among these groups. When poorer people with less education, those without formal employment and those who live in isolated rural areas do have access to health facilities, those facilities may turn out to be pretty unsafe. But that’s a matter for research that these NGOs haven’t yet carried out (or perhaps they just haven’t published it).

Ever-eager to snatch defeat from the jaws of victory, those who subscribe to the (eugenicist) population control theory of development in Africa, whether covertly or overtly, continue to receive generous funding. They don’t wish to lose any ground when it comes to pandering to the prejudices of those who still believe that Africans have loads of unsafe sex, and that this is why HIV prevalence is so much higher there. Yet, funding for unsafe healthcare always seems to put donors off their morning read, which is evidently when they set their funding priorities.

Since the early days of HIV/AIDS, finger pointing has been the main publicity angle. In Western countries the collective finger was pointed at men who have sex with men. Their reaction was to object to the finger being pointed at them and to insist that everyone is equally at risk. Though some still believe that everyone is equally at risk, it is not true. In Western countries the majority of HIV transmissions have always been among men who have sex with men, with a smaller proportion of transmissions through intravenous drug use.

But things are quite different in developing countries, particularly high HIV prevalence African countries. In high HIV prevalence countries men who have sex with men, intravenous drug users and even sex workers contribute a relatively small proportion of HIV transmissions. In fact, the largest contribution still appears to come from those with little or no risk; mainly monogamous heterosexuals. So the process of finger pointing often turns into one of victim blaming. After all, you can’t point the finger at everyone around you, nor at someone who is HIV negative; so the clearest ‘evidence’ of unsafe sexual behavior becomes HIV positive status.

This gives rise to the task of explaining how a virus that is difficult to transmit through heterosexual sex outside of Africa is so frequently transmitted through that route in Africa. The HIV industry needed to show that ‘Africans’ must be promiscuous, ignorant and unhygienic. This wasn’t too difficult because population control advocates (the word ‘eugenics’ is no longer fashionable), a significant proportion of wealthy NGOs operating in Africa, had had been playing the over-sexed, under-educated slum-dweller cards for decades.

The processes of pointing the finger at a particular group whose behavior was disapproved of, blaming those infected with HIV for their status, and concluding that HIV is all a matter of individual behavior, threw off course any efforts to reduce HIV transmission in developing countries. Although ‘prevention’ activities only receive a small proportion of HIV funding, that is still a massive amount of money. But prevention activities have rarely gone beyond exhortations to ‘behave’ in a particular way. The finger-wagging programs perfected by population control NGOs decades before HIV was identified became, and often remain, the state of the art of HIV prevention.

There has been plenty of research showing that these finger-wagging programs are of little or no benefit (except to the NGOs). An example of such research shows that “peer education programs in developing countries are moderately effective at improving behavioral outcomes, but show no significant impact on biological outcomes“. There is a voluminous body of literature showing that you can’t simply wag your finger at people and expect them to change their behavior, whether the aim is to address substance abuse, dangerous driving, over-eating or anything else.

Sometimes the association of HIV transmission with individual behavior is further connected with conditions that are beyond the control of the victim, for example, poverty. But this has also given rise to confusion: there is plenty of evidence that HIV in African countries is transmitted among wealthier people. This challenges the idea that HIV epidemics are driven by sexual behavior because, even if wealthy people ‘can afford to have a lot of sex and a lot of partners’, as the HIV industry would have it, there would need to be some poor people involved in this theory. Rich people don’t pay other rich people for sex.

Instead of looking beyond sex, or sex and poverty, it seems some researchers are convinced they will eventually find out how sex and economic inequalities ‘drive’ HIV epidemics. One paper concludes that “Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in [sub-Saharan Africa]“. But they don’t seem to consider the possibility that their protohypothesis about sex is simply wrong. They don’t seem to think that non-sexual transmission may be a very significant factor in the spread of HIV among wealthier people.

HIV can be transmitted through unsafe healthcare and other skin-piercing processes, such as various cosmetic processes. Wealthy people tend to have better access to healthcare. In fact, urban dwellers also tend to have better access to healthcare. Perhaps this is why the above paper found that HIV is “generally concentrated among wealthier men and women“. This may also explain why HIV “was concentrated among the poor in urban areas but among wealthier adults in rural areas” in a number of countries.

Instead of trying so hard (and failing, over and over again) to find out what it is about the sexual behavior of wealthy people and urban dwellers, perhaps researchers should look at non-sexual risks, as well as sexual risks. Could the risks that people face be determined by their wealth and environment, precisely because they are not sexual risks, but healthcare and other risks? These risks are clearly not *individual* risks. They relate to health-seeking behavior, but it is not the behavior of wealthy and/or urban-dwelling people that gives rise to infection with HIV in a hospital or salon; the risk of infection depends on whether the facility is safe or not (which might vary considerably over time).

Some historians of HIV, such as Jacques Pepin (The Origins of Aids), admit that HIV was mainly transmitted through unsafe healthcare for many decades, and hardly ever through sexual behavior. But they don’t explain how healthcare transmission magically disappeared in the 1980s even though conditions in many African countries remain very unsafe (although how unsafe they are is still a dangerously under-researched field).

Coupled with the magical disappearance of the risk of HIV transmission in under-equipped, under-staffed and badly run health facilities is the magical re-appearance of the promiscuous, ignorant and dirty African, though for many, this had never really gone away. Pepin vaguely mentions things like ‘urbanization’ as the main explanation for levels of promiscuity for which there has never been any evidence and which do not explain very high rates of heterosexual transmission of HIV anyway.

Ugandans have recently responded to having the finger pointed at them by allowing an ‘anti-homosexuality’ bill to be passed, effectively saying ‘it’s not us, it’s them’. Various human rights groups, and even some donors, may belatedly object to such disgusting measures, which are being copied by other African countries. But the objection needs to be directed at the approach to HIV that began a long time ago, and began in Western countries, not in African countries. Men who have sex with men are by no means the only group who have been blamed for HIV epidemics. Other groups include long distance drivers, sex workers, house girls, fishermen, miners, and many others. It’s this finger-pointing approach that gives rise to the stigma that those pointing the finger claim to abhor.

Thirty years into the HIV epidemic (I’m adopting the view that HIV is not a pandemic because most people don’t face any risk of being infected and prevalence is, and will remain, low in most countries) research institutions, NGOs, international bodies and, perhaps most importantly, donors are still obsessing about sexual behavior and pretending that HIV status is up to the individual when it is clear that a large, but as yet unestimated, proportion of infections is a result of unsafe healthcare and other skin-piercing processes.

UNAIDS risk missing their target of reducing “sexual transmission of HIV by 50% by 2015“. But there is a way of meeting that target, and they could meet it by tomorrow. If they belatedly admit that HIV is far more easily transmitted through unsafe healthcare, they could begin to estimate the contribution of things like reuse of needles, syringes and other equipment that comes into contact with blood and other bodily fluids.

This would also greatly assist their progress towards their ‘ZeroDiscrimination’ target too, because even though they can’t reverse the damage they have done by insisting that Africans are irremediably promiscuous, the status of this claim as institutionalized racism will eventually become clear, at least to those who are prepared to think the issue through a little (a surprisingly small number of people so far).

After all, reducing ‘sexual transmission’ is one of their stated goals, whereas UNAIDS has barely breathed a word about transmission through unsafe healthcare in their 20 year, multibillion dollar, celebrity studded reign. They could just quietly (imperceptibly, even) reveal some changes in the way figures are collected and next December 1, a re-estimation of non-sexual transmission of HIV could be the subject most deserving of their customary (spontaneous) standing ovation module.

UNAIDS are uncharacteristically frank about mass male circumcision, which is something of an embarrassing fiasco: “As of December 2012, 3.2 million African men had been circumcised […]. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011. Still, it is clear that reaching the estimated target number of 20 million in 2015 will require a dramatic acceleration.” (They don’t say how many of the 3.2 million circumcised over quite a few years would have been circumcised anyway but took advantage of the free (anesthetized) operation.) Might this spell an unobtrusive retreat from this dangerous imperialist program?

But one of the heftiest pieces of bullshit in the ‘report’ (and there is stiff competition) is about “the goal of providing antiretroviral therapy to 15 million people by 2015”. They say that “As of December 2012, an estimated 9.7 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.6 million over 2011. That brings the world nearly two-thirds of the way towards the 2015 target of 15 million people accessing antiretroviral treatment.”

The difference between UNAIDS’ claim and the truth is expressed in a few words, such as ‘were receiving’ therapy. If they said that 9.7 million people had been recruited on to a therapy program, that might have been true (or somewhat closer to the truth). But 9.7 million is, at best, the number of people who have at one time been put on a program. Neither UNAIDS, WHO, PEPFAR, CDC nor anyone else knows how many of those 9.7 million ever took the drugs, or for how long, how many dropped out of the program, how many were recruited on to two or more programs or simply died, etc.

No one knows, and no one really cares because 9.7 million is an impressive figure, and it sounds like a good attempt at the 15 million target. There is not much incentive to estimate how many people are alive and on antiretroviral treatment, indeed, such an estimate could prove fatal to several substantial institutions (not just UNAIDS, which seems to thrive on failure to achieve anything at all, aside from spending money and institutionalizing bigotry). Is the true figure 8 million people, 7 million, or some far lower number? Billions of dollars say that no one is going to ask this impertinent question (unless they are not in receipt of any of those billions, and never will be).

Unsafe healthcare does exist in extremely poor, high HIV prevalence countries, surprising as that may seem to those who are used to the mainstream view that HIV is hardly ever transmitted through heterosexual sex in every country in the world, but almost always transmitted through heterosexual sex in a handful of African countries. What contribution does unsafe healthcare make to the worst HIV epidemics in the world, all in sub-Saharan Africa? Would it be the one or two percent UNAIDS grudgingly suggests, or something far higher? We don’t know yet. No billions have been offered for the answer to this question.

Using cumulative figures is great, because you get that great ‘step’ effect when you produce bar graphs, and there is nothing like comforting, progressive steps to convince people that everything is good in UNAIDSland, and in the HIV industry in general. A very achievable 2015 target would be the abolition of UNAIDS and the promotion of safe healthcare. Because unsafe healthcare risks the spread of HIV, something UNAIDS has never got around to accepting. But I suspect that instead, there will be a continuation of the finger-pointing and victim-blaming that has characterized the mainstream approach to HIV in high prevalence countries so far.