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UNAIDS, Beckham and Sidibe: Right Words; Wrong Oriface

Every year, more than 1.5 million people are newly infected with HIV, the vast majority of them black Africans, with a lot more women than men being infected. Meanwhile, UNAIDS continues to insist that the virus is spread almost entirely through ‘unsafe’ sexual behavior in African countries, though nowhere else in the world. HIV via unsafe healthcare, they insist, almost never happens in countries with the worst healthcare systems in the world.

The institutional racism and sexism exemplified by UNAIDS, the broader UN, the World Bank, charitable foundations and other parties results in huge levels of transmission of a virus that is difficult to transmit through heterosexual sex; transmission through unsafe healthcare remains completely ignored, even denied, by what has become a massive HIV industry.

These institutionally racist and sexist stances also result in the implication that most of the people infected with HIV are highly ‘promiscuous’, careless, uncaring, stupid, and whatever other negative qualities the media happens to have been fed about HIV positive Africans at any given time.

There is no mainstream media coverage of these instances of institutional racism and sexism, no online campaigns to have UNAIDS abolished, no celebrity photo shoots with publicity obsessed naifs being paraded before an adoring (or despising) public, no newspaper articles, neither tabloid nor broadsheet.

Where are the academic articles by those whose entire time is spent, allegedly, examining and analyzing such phenomena and advising those putting together policies that should go towards reducing the transmission of serious diseases like HIV? Which academics are condemning the institutional racism and sexism that has continued, unabated, since HIV became a lucrative headline-grabbing disease in the late 1980s?

There’s plenty of media coverage of some ex-singer that UNAIDS hoped could belt out a few well rehearsed lines in front of a camera (and a sneering Michel Sidibe). A child actress did a better job of memorizing and spewing out the right lines and buzzwords, with the right facial expressions and body language, so she got some publicity too.

An exhibition that sounded (to some) like it would ‘insult’ black people, even though most of the people taking part in it were black South Africans, was banned because a few people managed to drum up a crowd of ‘insulted’ people who had never seen the exhibition. Though insulted by something they had never seen, they remain uninsulted by the continued treatment of black Africans as sex obsessed disease vectors; protestors scream about ‘objectification’, but fail to recognize it in the flesh.

Ultimately, what Victoria Beckham was saying was no more ridiculous than what UNAIDS and other institutions repeat endlessly. She’s just not very good at UN-speak; her mentors haven’t worked on her hard enough; give it time and she too will be able to trott out the same bullshit as the smirking head of UNAIDS does.

No one was infected with HIV by Beckham’s speech and, unlike the usual UNAIDS blather, it wasn’t even articulate enough to be considered racist or sexist. No black people were injured by an exhibition that never happened at the Barbican. The only ones insulted will be the ones who were told that the event was far too shocking for their poor delicate little selves. The truth, clearly, is far too dangerous for ordinary people to handle. Nice to know that the notion of a ‘protectorate’ has not died out completely.

Kenya’s HIV Prevention Revolution: Beating Swords into…Condoms

Kenya’s recently published ‘HIV Prevention Revolution Road Map – Count Down to 2030‘ presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country’s epidemic is.

Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned ‘King of Condoms’, with a paper crown on his head, demonstrating to the country’s first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don’t see that as an instance of crass infantilization? Perhaps they don’t find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed ‘Modes of Transmission’ spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn’t we start collecting empirical data to guide future efforts?

Millennium Development Goals For All, But At All Costs?

A survey was carried out in one district each in Kenya, Tanzania and Zambia to establish which factors are associated with health facility childbirth (thus shedding light on which factors are associated with the decision to give birth elsewhere, perhaps at home). Health seeking behavior is strongly associated with wealth, education, and urban residence; wealthier, better educated women living in urban areas, in general, are more likely to give birth in a health facility.

These factors are of especial interest because of their association with HIV. Wealthier, employed, better educated, urban dwelling women in African countries are often more, rather than less likely, to be infected with HIV. The tables below are for Kenya, Tanzania and Zambia, but these trends can also be found in other countries. The first table shows HIV prevalence by wealth quintile, with prevalence being lower among poorer people and higher among wealthier people.

Wealth quintile tableThe next table shows HIV prevalence in males and females, by employment and by urban/rural residence. Males are far less likely to be infected than females, unemployed people are less likely to be infected than employed people and rural dwelling people are less likely to be infected than urban dwelling people.

Employment residence

The third table shows that HIV prevalence is sometimes lower among those who have less education and higher among those with primary education in Kenya and Tanzania and those with secondary education and beyond in Zambia. (Note, figures for education are for attendance, not attainment, so they don’t tell you that much. But MDG 2 is about ‘achieving universal primary education’, not about academic attainment.)


Receiving antenatal care at a health facility is part of the Millennium Development Goal (MDG) number 5, to improve maternal health. Therefore, it is not surprising that all 14 African countries I have looked at have a very high score for this goal, all ready for 2015. But the goal does not consider matters such as conditions in health facilities, skills of providers, facility practices, equipment, supplies, etc. So the percentage of women delivering in health facilities and the percentage of deliveries attended by a skilled health provider are far lower, being out of the MDG limelight.

ANC tableFor information on health facility conditions, equipment and supplies, there are Service Provision Assessments for each of the three countries, showing that there are many serious lapses. But questions about whether skilled providers are skilled, and of how skilled they are, are less often asked (particularly in relation to the MDGs). Another paper, entitled “Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward“, addresses this issue.

Skill levels overall are not impressive and are low in some areas in the countries involved (Nicaragua, Benin, Ecuador, Jamaica and Rwanda). The researchers note that “knowledge of a procedure is no guarantee that it can be performed correctly”, but also that problems are not solely due to a lack of skills or training, that some are due to lack of equipment, supplies and other things.

The first article estimates that skilled birth attendance could substantially reduce maternal deaths “presuming that facilities meet standards of quality care.” Quite. But various sources of data show that health facilities often don’t meet standards of quality care. The possibility that health facilities may be the source of a considerable proportion of HIV infections in high prevalence countries must be considered urgently if healthcare transmitted HIV, and other diseases, are to be averted.

Reducing maternal deaths is a laudable goal, but it is nothing short of unethical to encourage women to attend health facilities where the conditions are likely to be unsafe. Right now, failing to achieve MDG 5 may even be preferable to achieving it. Of course deaths from hemorrhage, obstructed labor, puerperal sepsis and pre-eclampsia must be reduced, but not at the cost of increasing incidence of HIV, hepatitis and other bloodborne diseases.

Justine Sacco: Dangerous Truths and Dangerous Falsehoods about HIV

An American on her way to South Africa is said to have Tweeted “Going to Africa. Hope I don’t get AIDS. Just kidding. I’m white!” This is a heartless and insensitive remark to make. But what makes it most heartless and insensitive for a white American to say it is the fact that it is so true. In the US, African Americans accounted for 44% of all new HIV infections in 2010, despite representing only 12-14% of the population. Also in the US, men who have sex with men are said to represent about 4% of the population, but account for 63% of all new HIV infections in 2010, and a disproportionate number of them are black/African American.

Even in South Africa HIV prevalence among white people is very low. But national prevalence is amongst the highest in the world and there are more HIV positive people in South Africa than in any other country. While America has the worst HIV epidemic in the developed world, with over 1.1 million HIV positive people, the majority of infections arise among men who have sex with men and (to a lesser extent) intravenous drug users. HIV infection among white heterosexuals who have no serious risks, such as receptive anal sex or intravenous drug use, is very low.

The American who tweeted the first stupid, but sadly true, remark offended so many people that she arrived in South Africa to find that a storm had erupted on Twitter and she had lost her job. So, to make matters worse, she made a statement to a South African newspaper which contained a dangerous but often heard falsehood:

“For being insensitive to this crisis — which does not discriminate by race, gender or sexual orientation, but which terrifies us all uniformly — and to the millions of people living with the virus, I am ashamed.”

This is completely untrue, as the figures for the US show so clearly. About two thirds of people living with HIV globally are black Africans. An estimated 60% of HIV positive people in Africa are female, compared to only 20% of new infections in the US in 2010. Hispanics and Latinos in the US made up 21% of new infections in 2010; the rate of infection was 2.9 times higher in Latinos than it was in white males; it was also 4.2 times higher in Latinas than in white women.

HIV most definitely does discriminate by race, gender and sexual orientation. This is not a new discovery, either. It may be an acceptable thing to say in certain circles, but we should never forget the differences between HIV in Africa, where the majority of HIV positive people live, and HIV in developed countries, where HIV is less prevalent overall, and is rare among heterosexuals who have no serious risk behaviors.

Justine Sacco, who tweeted the remark, is so right to think that she is very unlikely to be infected with HIV; a lot less likely than a black African, and also less likely than a black or Latino/Latina American. It is disturbing to think that so many people continue to believe or say otherwise. Why is HIV prevalence so high among black Africans and black/African Americans, yet comparatively low among white people, especially white men who engage in no serious risk behaviors?

Happy New Year to All our Visitors

In our first two full years online the Don’t Get Stuck With HIV website and blog has received 48,000 page views, over 31,000 of them in 2013. The number of monthly views has increased to a high of 3,600 in December 2013 and the daily average has reached 116 views in the same month.

With over 7,000 views, our Blood-borne Risks page (‘Estimated risks to transmit HIV through various skin-piercing events’) was the most popular, followed by the home page, at 6,000 views. Sexual transmission risks, our pages about dental care, tattooing, hairstyling (etc), bloodtests and injections all received over 1,000 views each.

Also, a couple of blog posts were very popular, especially ‘Have we ignored a very simple procedure that could significantly reduce the risk of sexual transmission of HIV to men from women?‘ (nearly 2,000 views) and ‘Denied, withheld, and uncollected evidence and unethical research cloud what really happened during three key trials of circumcision to protect men‘ (1,600 views). A post on genital hygiene also received almost 1,000 views.

An analysis of about 4,000 search queries, comprising about 500 search terms, revealed that searches about syringes, other medical instruments and their uses accounted for about one quarter of all queries. Tattoos, dental care, manicures and pedicures and HIV transmission risk accounted for another 1,300 queries. About 260 searches were about circumcision if you add in searches for ‘Prepex‘, which is a fairly popular subject.

We have had visitors from 177 different countries, although we only 10 or fewer page views from 64 of those countries. With nearly 20,000 views from the US since February 2012, no other country comes close, although nearly 5,000 have been from the UK. India, Canada and Australia have accounted for another 7,000 views.The highest number of views from an African country was 864, from South Africa.

Our top referrer, accounting for over 30,000 views, was Google, mostly; about 3,000 were from Facebook, Reddit, Twitter and a few other tools account for a few hundred views each, although stimulating referrals from Facebook and Twitter required a disproportionate amount of work.

We thank visitors for viewing our site and blogs. We hope you found what you were looking for. We welcome comments and feedback and are grateful for what we have received so far. Using the above data, we intend expanding and reorganizing Don’t Get Stuck With HIV over the next year and hope we keep expanding.

All the best for 2014!

Outbreak investigations: Facing and fixing problems

If a hospital or clinic infects you or your child with HIV, you’d probably call it a disaster. Health care bureaucrats and managers call it an “adverse event.”  How often do patients get HIV from health care in Africa? The World Health Organization (WHO) has estimated it happens 50,000-100,000 times each year.  Other estimates are higher.

That’s a lot of “adverse events.” In more than 25 years, no international agency, no donor health aid program, and no African government has done the right thing to stop them.

When a department of health finds one or several unexplained HIV infections in patients that can be traced to a suspected hospital or clinic, the recommended “textbook” response is to investigate — to invite others who attended the same facility to come for tests to see how many, if any, others are infected. By finding others infected in the same outbreak, an investigation can pin-point the errors that did the damage. This alerts health care workers to fix things they didn’t know were problems, and warns patients to demand safe care. In this way, investigations save lives.

Consider the response to “adverse events” in other countries. For example, although the US health care system is not the best or safest in the world by a long shot, US state and federal governments have been doing the right thing in response to unexplained infections of hepatitis B and C virus. In health care settings, these viruses transmit just like HIV – from patient-to-patient through blood-to-blood contact when doctors and nurses reuse instruments without sterilization.

In 10 years from 1998 through 2008, the US Centers for Disease Control (CDC) recorded 33 investigations of hepatitis B and/or C transmission through health care in clinics, nursing homes, etc. Each investigation tested from 4 to >12,000 patients. The 33 investigations found a total of 448 hepatitis B and C infections from health care (average of 13 infections per outbreak). During the next 3 years, 2008-11, 32 investigations (including 3 from the previous list plus 29 new ones) invited a total of more than 90,000 patients to come for tests and identified a total of 217 infections (average of 7 per outbreak).

Did these investigations scare people to stay away from health care? Maybe some people got scared. But the real impact goes the other way: The fact that government is alert to investigate unexplained infections assures the public that someone is watching.

Consider the alternative – what happens when there are no investigations? Not investigating unexplained infections is like smelling smoke, ignoring it, and letting the house burn down. Or yelling at your dog to be quiet when she barks at night – and waking up to find your motorcycle missing.

Aside from a few HIV infections traced to blood transfusions, there have been no investigations of any of the thousands of recognized HIV “adverse events” in Africa. During 1991-93, for example, a WHO study in Rwanda, Tanzania, Uganda, and Zambia identified 61 children aged 6-60 months who were HIV-positive with HIV-negative mothers. There is no report of any investigation in any of the four countries to find the source of these unexplained infections. Incredibly, the WHO study team concluded “The risk of nosocomial [hospital-acquired]…HIV infection appears low among these populations.”

Ideally, foreign experts and agencies would be at the forefront to help with investigations. That has not happened.

Lack of interest on the part of international agencies and donors leaves African governments with the task. Which government will take the lead to begin to investigate unexplained HIV infections? Investigations are not expensive in monetary terms – but they may ruffle feathers. Someone has to push — to persuade health care bureaucrats to recognize and investigate HIV “adverse events.”

Have we ignored a very simple procedure that could significantly reduce the risk of sexual transmission of HIV to men from women?

This was written together with Joseph Sonnabend [go to or return to first circumcision page]

In 2010 there was a great deal of outraged comment about the US government’s award of $823,000 to an HIV related project in Africa. Specifically, the taxpayer dollars were to be used to teach uncircumcised African men how to wash their genitals after having sex. The grant states; “If we find that men are able to practice consistent washing practices after sex, we will plan to test whether this might protect men from becoming HIV infected in a later study.”

The reasoning behind the project was based on the assumption that the reported protective effect of male circumcision was due to improved genital hygiene. This is in the project description:

“The protective effect of male circumcision on HIV acquisition may be due to improved genital hygiene. We propose to evaluate the feasibility of a post-coital genital hygiene study among men unwilling to be circumcised in Orange Farm, South Africa. Men in high prevalence settings could potentially benefit from improved genital hygiene if this intervention proved to be efficacious in reducing HIV acquisition risk” Genital hygiene was to be improved by asking men to wash their penis after sex.

Widespread criticism of such a use of public funds might have missed the main problem. As it turns out, not washing immediately after sex may actually have a significant protective effective for men at risk from heterosexual intercourse – including both circumcised and uncircumcised men

This was noted in two randomized studies of male circumcision to prevent HIV infection in the Rakai region of Uganda in 2003-2007. Although the effect of washing on HIV acquisition received some media attention at the time its relevance to HIV prevention remained generally unnoticed. It apparently also remained unnoticed or considered to be of no consequence to the applicants as well as the funders of the $823,000 grant noted above.

Combining results from these two trials, Tobian and colleagues in an article in AIDS in 2009 report information on risks for 105 HIV seroconversions in 6,396 initially HIV-negative men observed during 9,604 person years (PY) of follow-up. Half the men were circumcised for the trial and half remained uncircumcised.

These 105 HIV seroconversions represent 1.09 infections per 100 PY.

Among the questions that trial participants were asked in attempting to define risks for HIV infection was whether or not they washed their genitals after sex.

Among men who did so there were 1.35 infections per 100PY compared to only 0.38 infections per 100PY among men who did not wash their genitals. The adjusted relative risk for washing vs. not washing was 3.04 (95% confidence interval: 1.11-8.33; P = 0.031).

The authors make the following comment in their discussion,

“The finding that HIV incidence was increased with washing genitals after sexual intercourse is counterintuitive, but supports previous finding that washing the penis within 10 min of sexual intercourse increases the risk of HIV acquisition among uncircumcised men. The increased HIV acquisition with penile washing may be due to the removal of acidic vaginal secretions or the addition of water with a neutral pH may assist HIV survival and infectivity”.

The “previous finding” referred to is an earlier report by Makumbi and colleagues in 2007, who interviewed 2552 uncircumcised men enrolled in the control arm of a randomized trial of circumcision for HIV prevention in the Rakai region of Uganda (these men are included in the data reported by Tobian and colleagues in 2009). Some of the information reported by Makumbi and colleagues is shown in the last four slides in this presentation prepared by i-Base, UK.

This is one of the slides showing that there were 2.32 HIV infections per 100PY among men who washed their penis within 3 minutes of intercourse, but only 0.39 infections per 100PY among men who waited for 10 minutes or longer before washing.

If we were to express the efficacy of delayed washing in the same way that the results of PrEP trials were reported, that is as relative risk reductions, this would mean that not washing immediately, but waiting for at least 10 minutes after intercourse before washing can reduce the risk of infection by 83%. Compare this to the 44% efficacy of Truvada in the iPrEx trial, the 39 % efficacy of tenofovir gel in reducing the risk of infection in women in the Caprisa 004 trial, and the 38-66% efficacy reported for circumcision over 24 months.

Genital washing after sex may be quite common in parts of Africa. A study in Nairobi in 2004 found that a majority of men washed their genitals after sex. Here is a link to a table in the report; 60% of men reported always washing their genitals after sex.

We have had evidence that this practice may contribute to the risk of HIV infection in men since 2007. We have to wonder if the many questions this raises have been addressed, or even considered.

Could the practice of immediate post-coital genital washing contribute to the risk of sexual transmission of HIV to men?

Are there regional variations in this practice, and could this be related to HIV prevalence to some extent?

Should there be a debate on the evidence by experts, with recommendations for further research – such as adding questions to on-going or proposed studies, laboratory testing of HIV viability in semen and vaginal fluids at body temperature or conducting a trial to nail down the risk of immediate washing, or in other words, the protective effect of delayed washing?

If immediate washing increases the risk of infection does this not raise the question of the extent to which infection occurs after withdrawal?

Considering how innocuous the intervention is do we have sufficient evidence now to advise African men at risk of HIV through heterosexual contact not to clean their penis for at least 10 minutes after sex? Should a dry cloth without water or soap be used?

The study teams for these trials have more information on post-coital penis cleaning that they have not reported. We know that for uncircumcised men, wiping was safer than washing, and waiting at least 10 minutes to clean significantly reduced risk for HIV (see the last several slides in this reference. But we don’t have similar details for circumcised men. What information has been collected but not reported?

We have evidence that a common practice, at least in certain regions can substantially increase the risk of HIV infection in men through heterosexual intercourse. Considerable attention has been given to newer prevention methods in the past few years, notably pre – exposure prophylaxis and male circumcision, but almost none to the simplest of procedures that may be even more effective in preventing the sexual transmission of HIV.

Many other questions and concerns will no doubt arise as more people look at the evidence, and figure out what to do about it. Lives are at stake. Scientific competence and integrity are also at stake – researchers have overlooked and/or incompletely reported information that could save lives.

Lessons from North American outbreaks – changing needles alone is not enough

[go to first injections page] [Note: Stephen F. Minkin ( submitted the following as a guest blog.]

The CDC [US Centers for Disease Control and Prevention] first reported on four large outbreaks of hepatitis B and hepatitis C at outpatient medical facilities between 2000 and 2002. Two outbreaks occurred in a private physician’s offices in New York, one at an Oklahoma pain remediation center, and one at a hematology/oncology clinic in Nebraska. A total of 247 patients were known to have been infected at these facilities.

In addition, unsafe practices were uncovered at a phlebotomy center in California in 2001, where needles for drawing blood were reused. As a result, 15,000 people had to be tested for HIV, hepatitis B, and hepatitis C.

Two more recent outbreaks discovered in Nevada and New York garnered considerable media attention. In November 2007, reports surfaced that a New York anesthesiologist reused syringes when withdrawing medicine from multi-dose vials. In the process he potentially exposed thousands of patients to blood-borne viruses. On December 14, 2007 the New York Department of Health contacted approximately 8,500 patients exposed by this practice and urged them to be tested for Hepatitis and HIV.

On February 29, 2008 health officials in Las Vegas closed the Endoscopy Center of Southern Nevada after six patients were diagnosed with hepatitis C.  The outbreak was traced to nurse anesthetists reusing syringes to draw up medicine from single use vials for multiple patients.

According to the CDC,

A clean needle and syringe were used to draw medication from a single-use vial of propofol, a short acting intravenous anesthetic agent.  The medicine was injected directly through an intravenous catheter into the patient’s arm.  If a patient required more sedation, the needle was removed from the syringe and replaced with a new needle; the new needle and old syringe was used to draw more medication.

This was a “common practice” at this center for at least 4 years. As a result 40,000 patients were potentially exposed to this risk of hepatitis and HIV infections.

The CDC suggests two possible ways the syringes could have been contaminated.

Backflow from the patient’s intravenous catheter or from needle removal might have contaminated the syringe with HCV (hepatitis C) and subsequently contaminated the vial. Medication remaining in the vial was used to sedate the next patient.

Investigators concluded that each of these outbreaks resulted from “unsafe injection practices primarily the reuse of syringes and needles or contamination of multiple-dose vials leading to patient to patient transmission” (page 901 in this link).

The changing of needles while reusing the syringe is very, very risky and is not a WHO recommended practice (page 35 in this link).

The 2002 Oklahoma outbreak was traced back to a nurse anesthetist supervised by an anesthesiologist at a hospital outpatient clinic. In response the American Association of Nurse Anesthetists (AANA) mailed copies of the AANA Infection Control Guidelines to its members

The organization also hired a research firm to conduct a random telephone survey of Certified Registered Nurse Anesthetists (CRNAs) and anesthesiologists “to learn more about practices and attitudes on needle and syringe reuse.”  A spokesperson termed the finding as “eye opening.”

Among the different categories of health professionals surveyed, 3 percent of anesthesiologists who responded indicated they reuse needles and/or syringes on multiple patients. CRNAs, other physicians, nurses and oral surgeons reported reuse at 1 percent or less.

Extrapolating the survey findings – 3 percent of anesthesiologists plus 1 per cent of CRNAs – equated in 2002 to approximately 1,000 anesthesia professionals who might have been exposing more than a million patients to the risks of contaminated needles and syringes.

They were forced to revisit the problem of the reuse because of the events in New York and Nevada. On March 6, 2008, Dr. Wanda Wilson, the AANA President, commented on the sad state of affairs.

It is astounding that in this day and age there are still nurse anesthetists, anesthesiologists and other health professionals who still risk using needles and syringes on more than one patient, or know of such activities and don’t report them. Published standards and guidelines dictate that single-use and disposal of these products is the best way to ensure patient safety. Patient safety is our primary focus – not cost savings, time savings, or any other factor

If the hepatitis C outbreaks in New York and Nevada demonstrated anything, it was that such incidents occur regardless of a provider’s degree, credentials, or title.  For any group to suggest otherwise is to put its collective head in the sand—it is irresponsible, negligent, and a sure invitation for yet another Nevada or New York situation to occur.

A 1990 study by Canadian researchers experimentally examined the risk of cross infection related to the multiple use of disposable syringes connected to IV tubing during anesthesia.  The authors were motivated because  “the practice of reusing disposable plastic syringes for several patients is still prevalent in North American operating rooms despite warnings about possible hazards.”

In some operating rooms, the usual practice is to reuse disposable syringes while changing needles.  This practice is based on the assumption, that since only needles enter the injection site, it is the only part that can be contaminated.  A high proportion of reused syringes were contaminated even if only the needle had contact with blood.  The probable mechanism of contamination is by aspiration into the syringe of blood remaining in the needle because of the negative pressure generated while removing the needle.

In view of these finding the authors emphasized that “changing needles alone is a useless procedure to prevent contamination.”


Wait and wipe, don’t cut

[go to or return to first circumcision page]

Last week, while looking for something else, I ran across a report that has big implications for HIV/AIDS prevention in Africa: Almost five years ago, a trial of circumcision to protect men in Rakai, Uganda, reported that intact (uncircumcised) men who waited at least 10 minutes after sex before cleaning their penis were at less risk to get HIV than men who had been circumcised: intact men who waited to clean got HIV at the rate of 0.39% per year compared to 0.66% per year for circumcised men. Although the study team reported these results to an international AIDS conference in 2007, and several newspapers wrote about it at the time, the report has dropped out of view. That is a big mistake.

Why is this report important? Here are three reasons.

First, if you are intact, this report says you don’t need to get circumcised to reduce your risk to get HIV. Use a condom, of course, if your partner has or might have HIV. But if that fails, this report says you are as safe with a foreskin as you would be without one. Just don’t clean your penis for at least 10 minutes after sex, and then wipe it with a dry cloth, without water. A later report from the Uganda study team suggests waiting to clean is good for all men, both circumcised and intact: men who didn’t “wash genitals after sexual intercourse” got HIV less than 1/3rd as fast as men who did.

Second, if you are a politician or public health official who is considering whether to go along with the largely US-promoted program to circumcise 20 million African men by 2015, you can take another close look at the evidence and options. The evidence that advocates use to promote circumcision comes from three studies (in South Africa, Kenya, and Uganda during 2002-06) that recruited thousands of intact, HIV-negative men, circumcised some and not others, and then followed and retested them to see who got HIV. All three studies reported that circumcised men got less HIV. But the study team for at least one of those trials – the trial in Uganda – has data showing that intact men who waited to clean after sex got less HIV than circumcised men.

Circumcision is expensive and dangerous and takes doctors and nurses away from other tasks. Why put scarce public resources into campaigns to circumcise millions of men if you can get the same results by advising men to use condoms, and if that fails to wait least 10 minutes after sex before wiping their penis with a dry cloth?

Third, this is another example of people reporting important evidence that contradicts well-funded misinformation about HIV risks. WHO, USAID, and other organizations pay for a lot of messages – some are true and helpful, but some are at best only partial truths. It’s important for people to speak up when they have good information about how to avoid HIV risks, even though what they say disagrees with the official “line” at the time.

Here are some examples of truth meeting official misinformation.

WHO warns UN employees they might get HIV from health care in Africa, but doesn’t warn the African public. But not everyone goes along with such misinformation. For example, Demographic and Health Surveys finds and reports HIV-positive children with HIV-negative mothers (in Mozambique, Swaziland, and Uganda) and virgin men and women with HIV. As more people speak up, Africans hear that a lot of infections come from minor blood exposures, and learn how to protect themselves.

Another example of official misinformation is WHO’s continuing promotion of Depo-provera injections for birth control without warning Africans that good evidence shows – and many experts believe – using Depo-provera increases a woman’s risk for HIV. One expert who has spoken out – eloquently and repeatedly – on this issue is Paula Donovan, a former high-ranking UNICEF official, who has had the heart and courage to challenge official misinformation.

Circumcision is another issue with a lot of well-funded misinformation, but also with many people speaking out to set the record straight (eg, see the article by Daniel Ncayiyana, editor of the South African Medical Journal, in this link). Unfortunately, crucial evidence is still unreported from the three key trials of circumcision to protect men: A lot of men in the trials got HIV despite no reported sex partners – what were their risks? None of the three study teams has reported the HIV status of any of the men’s sex partners, and only two have reported minimal information about blood exposures.

As for waiting and wiping to reduce HIV risk, here’s the record of partial and incomplete information from the 2003-06 trial of circumcision to protect men in Rakai, Uganda:

13 December 2006: The US National Institutes of Health reported that men circumcised in the trial had 48% lower HIV incidence compared to intact men, WITH NO MENTION OF POST-COITAL CLEANING.

24 Feb 2007: The Uganda study team reports selected trial data in Lancet, concluding: “Male circumcision reduced HIV incidence in men… Circumcision can be recommended for HIV prevention in men.” THE ARTICLE MAKES NO MENTION OF WAITING TO CLEAN, WHICH THE TEAM’S UNDISCLOSED DATA SHOWED TO BE MORE EFFECTIVE THAN CIRCUMCISION.

28 March 2007: WHO announces recommendations from an experts’ meeting: “Based on the evidence presented…experts attending the consultation recommended that male circumcision now be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men.” SEVERAL MEMBERS FROM THE UGANDA STUDY TEAM TOOK PART IN THE MEETING. THERE IS NO INDICATION THEY TOLD ANYONE ABOUT THEIR UNDISCLOSED EVIDENCE THAT WAITING TO CLEAN WAS MORE EFFECTIVE THAN CIRCUMCISION IN PROTECTING INTACT MEN FROM HIV.

25 July 2007: Frederick Makumbi and several other members of the Uganda study team tell an international AIDS conference: Among intact men reporting post-coital cleaning with all partners, “HIV incidence was significantly higher among those reporting cleansing within 3 minutes (2.32/100 py [person-years]), compared to those reporting a delay of more than 10 minutes (0.39/100py [person-years…).” (The best source i have found for these data is the last several slides in this link.)

So there you have it: In December 2006, the Uganda study team reported that circumcised men got less HIV than intact men. Not until 8 months later, in July 2007, did they disclose evidence that intact men who waited to clean their penises got less HIV than circumcised men. Despite their 2007 report, the Uganda study team has continued to say that circumcision is the way to go, and has said nothing more about waiting to clean as an effective option to reduce HIV risk for intact men.

Africans facing HIV risks from both blood exposures and sex need good information. Well-funded official fountains of stigmatizing misinformation blame Africa’s HIV epidemics on too much sex and too many foreskins. But there are also a lot of people offering good information and evidence. As more people speak up – telling what they know about HIV risks, even if it does not coincide with the party line – the African public will get a better idea about HIV risks and how to protect themselves.

SAVE families, stop HIV!

The International (formerly African) Network of Religious Leaders living with or Affected by HIV/AIDS (INERELA+) promotes SAVE as a response to Africa’s HIV/AIDS epidemic. SAVE stands for: Safe sexual and skin-piercing behavior; Access to treatment; Voluntary counseling and testing; and Empowerment. This note considers some of the ways that SAVE could strengthen HIV prevention in Africa.

AIDS was first recognized in Africa in 1982. In 2010, 28 years later, the World Health Organization (WHO) estimated that 22.9 million Africans were living with HIV, including 1.9 million with new infections in that year. These infections are not distributed evenly. The people most at risk live in cities in 15 countries, primarily in Southern and Eastern Africa. In these cities, from 20% to more than 50% of men and women aged 15 years today can expect to get HIV at some time during their lives.

Help husbands and wives stop intra-familial HIV transmission

Unlike Western countries, where almost all HIV transmission occurs outside families, a lot of HIV transmission in Africa happens within families – mother-to-child and spouse-to-spouse transmission together account for an estimated 45% of new infections.

(a) Mother-to-child transmission: According to WHO estimates, 390,000 babies in Africa got HIV from HIV-positive mothers in 2010, accounting for an estimated 20% of 1.9 million new HIV infections in Africa in that year (390,000/1,900,000 = 20.5%, rounded to 20%).

(b) Spouse-to-spouse transmission: An estimated 30% of all HIV-positive adults in Africa are married to HIV-negative partners, and the resultant spouse-to-spouse transmission accounts for approximately 470,000 HIV infections per year, equivalent to 25% of all new infections each year (470,000/1,900,000 = 25%). (A note at the end of this blog shows the source of these data and explains this estimate.)

Most Western experts continue to identify high risk groups in Africa, as in the US and Europe, according to extramarital sex – prostitutes, clients, truck drivers, and youth are considered to be at high risk because they have more than average levels of extramarital sex. But in Africa, none of these groups defined by extramarital sex has risks as high as babies born to HIV-positive mothers (without treatment, 35% are infected in 2 years) or spouses not aware their partners are HIV-positive partners (8% per year). In other words, the term “high risk groups” in Africa applies first and foremost to persons with intra-familial risks.

With good information and with some medical assistance husbands and wives can work together to stop 700,000 infections per year – reducing mother-to-child transmission by 320,000 (from 390,000 to 70,000) and spouse-to-spouse transmission by 380,000 (from 470,000 to 90,000; see the note at the end of this blog). This would reduce total HIV transmission from all causes by 37% – from 1.9 million to 1.2 million infections per year. There are two major challenges to achieve this outcome.

The first challenge is to reform and extend couple counseling. A lot of men and women don’t think they could have HIV because they and their partner have had very conservative sex lives. Many women who test HIV-positive are afraid to tell their husbands and/or assume they got it from their husbands, so there is no reason to tell them. The best way to overcome these testing problems is to make it clear – both in public messages as well as in counseling – that a lot of HIV in Africa comes from blood exposures. This is important for couples to know – it means an HIV infection is not a reliable sign of sexual behavior. It also means that conservative sexual behavior provides no assurance that anyone is HIV-negative.

It will take some work to get people to realize that their own or their spouse’s HIV infection might well have come from a skin-piercing event, because this realization has to overcome several decades of stigmatizing and misleading half-truths – blaming victims for their infections rather than acknowledging that unsafe health care has been an important part of the problem.

Once husbands and wives can go get tested and talk with each other about their HIV test results without distrust and blame generating family crises, then couples will be better able to plan for what to do to protect babies and uninfected spouses, and to care for those who are infected. Aside from changing messages to de-link HIV from sex, testing should be readily available, with or without counseling. People should be able to buy kits to test themselves (as in South Africa). Opt-out testing is a good way to go. However, compulsory testing is almost always a bad idea.

The second challenge is for governments and donors to prioritize prevention of mother-to-child transmission in allocating scarce resources for HIV prevention. Protecting babies will take a lot of money and medical personnel. This requires: testing pregnant women; testing husbands to get them involved; giving anti-viral drugs to HIV-positive women and their new babies; and helping HIV-positive mothers wean early (after 6 months is a common recommendation, but some may want to do so earlier or later). With these interventions, infected mothers will infect less than 5% of their babies, which would cut the annual number of infections from mother-to-child by an estimated 320,000 (from 26% to 4.5% of babies born to 1,490,000 HIV-positive mothers). Even lower rates of mother-to-child transmission can be achieved with anticipated new drugs or other options.

Whereas preventing mother-to-child transmission requires substantial assistance from outside the family, once husbands and wives know one of them is HIV-positive, they can protect the HIV-negative partner with little or no outside assistance. Condoms are almost 100% effective against sexual transmission (some studies reporting lower efficacy did not consider that condom-users might have gotten HIV from bloodborne risks). If the HIV-positive partner is eligible for antiretroviral treatment and achieves a low viral load, unprotected sex may be safe. If the wife is HIV-positive, circumcising the husband might reduce his risk, but he would not be safe without other protection (eg, condoms). Couples must also take care to avoid blood-to-blood contact through shared razors, toothbrushes, syringes and needles, etc.

Stopping HIV from getting into families

Extra-familial HIV transmission threatens families as well. Some men but many more women get HIV before they are married and bring it into the marriage. But that’s not all – even among old married couples, most couples with HIV are discordant. Husbands and wives continue to import HIV into marriages. According to Western ideas about HIV epidemics that have been imposed on Africa, all these infections come from sex. But those ideas don’t fit facts. Surveys find a lot of HIV in babies with HIV-negative mothers, in young and old virgins, and in men and women married for years with no outside partners and an HIV-positive spouse.

The best way to protect families from outside risks is to warn them about all risks, from blood contacts as well as from sex. African governments could improve these warnings by belatedly asking researchers and investigators to trace a lot of HIV infections to their source to see what risks are infecting babies, young women, etc — including especially people with limited and no sexual risks.

Conclusion: focus on the family

Whereas HIV in the US and Europe has been a tragedy for men who have sex with men and has largely avoided families, in Africa it hits families hard – weakening and killing husbands and wives, interfering with child-bearing, killing babies, taking huge expenses for treatment, and threatening family trust.

African families are strong and can carry much more of the burden to fight the epidemic. To do so, they need honest information – that an unknown but important proportion of infections comes from unsterilized instruments in health care and cosmetic services. Such messages not only allow people to see and avoid risks, but also make is easier for husbands and wives to test and to share HIV test results – the foundation for intra-familial HIV prevention.

Enlisting families to cut intra-familial transmission and supporting them with programs to prevent mother-to-child transmission could cut HIV transmission in Africa by an estimated 700,000 infections per year (37% of total transmission). This can be achieved with available budgets and personnel; but because these resources are limited, governments and donors would have to prioritize. One program that competes for money and personnel asks for $1.5 billion$2.7 billion and several thousand surgical teams to circumcise 20 million men by 2015. Critics argue, inter alia, that condoms are more reliable. But even if one ignores the critics, circumcision looks like an expensive distraction: even advocates estimate the 20 million circumcisions would reduce annual HIV transmission by less than 200,000 (10% of total transmissions) in 2015 – far less than can be achieved with the intra-familial focus proposed in this note.

Statistical note: According to WHO, 19.8 of the total 22.9 million Africans living with HIV in 2010 were adults (page 210 of this link). From national surveys in several dozen African countries over the last decade, the percentage of adults with HIV who are married ranges from roughly 53%-77% for men and 49%-69% for women (see Table below). From the same source, the percentage of adults with HIV who are married to HIV-negative partners ranges from roughly 10%-25% in the worst epidemics in Southern Africa to 25%-35% in mid-range epidemics in East Africa, to 50% in countries with low level epidemics (see Table below).

From these data, an estimated 5.9 million HIV-positive adults (30% of 19.8 million adults) are married to HIV-negative spouses. In studies that followed discordant couples who were not aware of their infections, approximately 8% of HIV-positive partners infected their spouses each year. Thus, 5.9 million HIV-positive adults in discordant couples infect an estimated 470,000 spouses each year (0.08 x 590,000 = 470,000). Assuming that expanded testing and couple counseling reaches all discordant couples, and that they use condoms and take other precautions to cut spouse-to-spouse transmission from 8% to 1.5% per year, this would reduce annual spouse-to-spouse HIV transmission in Africa by 380,000 per year, from 470,000 to 90,000.

Table: HIV in adults, married adults, and married adults with HIV-negative partners (selected countries in Africa)

Country year Sex % adults who are HIV+ % HIV+ who are married Among married HIV+ people, % with a spouse who is HIV- % of HIV+ people with a spouse who is HIV-
A B C = AxB
DR Congo 2007 Men 0.9 53 75 40





Burkina Faso 2003 Men 1.9 75 70 53





Ethiopia 2005 Men 0.9 77 73 56





Ghana 2003 Men 1.5 75 62 47





Tanzania 2007-08 Men 4.6 70 58 41





Uganda 2004-05 Men 5.0 72 45 32





Kenya 2008-09 Men 4.3 67 47 31





Mozambique 2009 Men 9.2 74 52 39





Zambia 2007 Men 12.3 56 45 25





Lesotho 2009 Men 18.0 65 33 21





Swaziland 2006-07 Men 19.7 54 21 11





Source: data are from country surveys available at this link; click on the country, and then on DHS (Demographic and Health Survey) or AIS (AIDS information surveys.