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Hepatitis B Virus and Kenya’s Mass Male Circumcision Programs – Why the Secrecy?

Comments Off on Hepatitis B Virus and Kenya’s Mass Male Circumcision Programs – Why the Secrecy? Posted by on July 2, 2014

With all the posturing in the recently released Kenya Aids Indicator Survey (2012) about mass male circumcision, whether performed in completely unsterile conditions found in traditional settings or the (hopefully) more sterile settings of health facilities, nothing was mentioned about hepatitis B or C. But an article in the East African describes a piece of research carried out by the Kenya Medical Research Institute into hepatitis B (HBV) which finds that prevalence is increasing.

Amazingly, the article admits that the “modes of transmission [for HBV] are similar to HIV — sexual transmission, contaminated blood products and mother to child transmission”; it is “passed from person to person through bodily fluids such as blood, semen or vaginal fluids”. Following a recent paper on HIV transmission through medical injections, it is very important to stress that HIV, like HBV, can be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

The article is equally frank about the lack of research into HBV in Kenya: “scientists say the reason for the rise in HBV in Kenya is still unknown since no scientific study has been done to explain the phenomenon”. In contrast, the HIV industry is a lot less frank about non-sexual HIV transmission, even though the country’s Infection Control Policy admits that “Epidemiological data on HAIs [Healthcare Associated Infection] in Kenya is currently lacking, but the risk for HAIs is high”. Slowly, some of these glaring gaps in research are being filled in, though the HIV industry displays a confidence that seems entirely unjustified.

Importantly, HBV among blood donors in Kenya is rising. Are those donating their blood being exposed to contaminated medical instruments through the blood transfusion services? The Kenyan Blood Transfusion Service is not able to supply enough blood to keep up with current demand, so they would need to make sure that people who donate are not being put at risk of infection with HBV or other blood borne viruses. While no one would want to scare people away from health facilities or from blood donation, keeping risks a secret would surely be a lot worse, wouldn’t it?

The article suggests that the counties finding high rates of HBV are in the Northern parts of Kenya (which often have the lowest HIV rates). It is suggested that “The likely causes of HBV in the region are cultural practices like tattooing, circumcising without using sterilised implements and because the regions are dry and people may not be able to get proper nutrition that ensures strong immunity.” As usual, there is a reluctance to ask if health facilities might also be somewhat responsible; does that mean these facilities will not be investigated, and that conditions, if unsafe, will not be improved?

There are various hepatitis related campaigns, but are WHO and other international health institutions going to ensure that all the people involved in the country’s mass male circumcision programs, will be protected from infection with HBV and hepatitis C virus (HCV) as well? WHO makes vague claims about huge proportions of HBV and HCV being transmitted as a result of unsafe healthcare. But what exactly are the figures for ‘priority’ mass male circumcision countries? Again, it’s likely that healthcare safety is more of a risk in these ‘priority’ countries, some of the poorest countries, with amongst the lowest levels of healthcare spending in the world, than it is in Western countries; why are we only given one, generalized figure, when the viruses must be much more prevalent in some countries than others?

Egypt, as (just one) example of a country with a serious hepatitis problem, has seen the figure for years of life lost (YLL) through HBV increase by 3,930% in the 20 years from 1990 to 2010. Liver cancer has increased by 361% in the same period. Cirrhosis has increased by 40% to become the number three cause of YLL, accounting for 1,127,000 YLLs, or 7.1% of all YLLs. Whether the almost 100% prevalence of circumcision in the country contributes to these figures is another question, but it shows what can happen in a country where there is a very high level of access to healthcare, yet where healthcare safety is not adequately addressed. One of the main reasons HCV prevalence is higher in Egypt than anywhere else in the world is because of schistosomiasis vaccination programs, which were carried out using inadequately sterilized glass syringes.

Reusable syringes and needles are no longer commonly used, but the WHO data shows that there is still a problem with unsafe injection practices. So the last thing high HIV prevalence African countries need is a vastly increased risk of bloodborne virus transmission through unsafe healthcare, whether this involves reuse of injecting equipment or other items that are used to pierce the skin during healthcare procedures. Mass male circumcision programs will likely increase the incidence of unsafe healthcare practices, including injections, and the WHO’s claimed benefits in terms of averted infections may not be enough to outweigh the risks involved.

Even if levels of protection against sexually transmitted HIV outweigh the risks, and this is highly debatable (and debated, outside of the HIV industry), what about the risks of infection with HBV, HCV or other bloodborne pathogens, including HIV, during the circumcision procedure itself? Some recent research has questioned the safety of Kenya’s health facilities. There are clearly more risks than those pushing the circumcision programs would like to admit; so will those who succumb to HIV industry pressure be advised of those risks? I suspect they will not.

AIDS, blood, HIV, iatrogenic, nosocomial , , , , , , ,

HIV Eradication May Require Regime Change in HIV Industry

Comments Off on HIV Eradication May Require Regime Change in HIV Industry Posted by on June 30, 2014

Having collected the data in 2012, the Kenya Aids Indicator Survey (KAIS) was released last week. Prevalence has fallen in most provinces. The exceptions are Northeastern Province, where data was not collected due to civil unrest, and Nyanza, where prevalence has increased from almost 14% in 2008 to 15% in 2012. 37% of Kenya’s HIV positive people reside in Nyanza. So the news is not so bad if you don’t come from Nyanza, especially if you don’t come from any of the exceptionally high prevalence towns on the shores of Lake Victoria.

Prevalence is now 5.6%, closer to Tanzania’s 5.1% than Uganda’s 7.2%. As usual, HIV prevalence is generally higher among women (6.9%) than among men (4.4%), higher among urban dwelling people than rural dwelling people and higher among employed people than unemployed people. Prevalence is lowest among females and males who have less education and higher among those who have completed primary or reached secondary or beyond. Prevalence tends to be higher among wealthier quintiles in rural areas and among poorer quintiles in urban areas, which may represent a change in HIV prevalence by wealth quintiles in earlier surveys.

With about 100,000 people being newly infected each year, incidence is said to be 0.5% and the highest number of new infections occurred among people aged between 25 and 34 years, with incidence estimated at 1.2%. Incidence has barely changed between 2007 and 2012, what the report refers to as ‘stable’. The entire epidemic could be described as stable, rather than declining, as prevalence has remained much the same for more than ten years.

Predictably, there are quite a few figures relating to the mass male circumcision program. You don’t put tens of millions of dollars into a program without making sure that you collect data showing that the program was successful. Clearly the program is not successful yet, with the bulk of circumcisions claimed for Nyanza province, which has a prevalence figure nearly three times the national figure. But there is a lot of triumphalist stuff about how high HIV prevalence is among uncircumcised people. Of course, none of the data throws any light on why HIV prevalence is so high among people in this province, so high among Luo people especially, yet not among Kisii or Kuria people.

The level of bullying and manipulation by those running mass male circumcision programs (which the HIV industry likes to refer to as voluntary medical male circumcision or VMMC) becomes apparent when you read some of the literature. Although the invasive operation’s claimed protective value against HIV (and goodness knows what else) has never been very convincing, people are systematically browbeaten over a period of years about hygiene benefits, which have never been demonstrated at all, ‘modernity’ of circumcision, ease of using condoms, increased sexual pleasure and a host of other things for which there is no evidence whatsoever.

According to the abstract “older men should adopt the practice to serve as role models to younger men”, as if there is some moral value in circumcision being provided by a benevolent dictator. UNAIDS addsn a commonly heard claim about “queues of young men and boys awaiting” mass male circumcision, which is clearly drawn from publicity materials rather than from any kind of independent research.

Talking of invasive operations, there is a chapter on blood and injection safety, ironically appearing straight after the mass male circumcision chapter. The figures for blood safety do not sound very encouraging, especially remarks about ‘misclassifications’ in donor records. UNAIDS’ ‘all men are bastards, all women are victims’ theory of HIV transmission gets a bit of a knock as well since nearly four times as many men as women said they donated blood in the 12 months before the survey. The findings about injection safety have been mentioned already on this site  when a full paper was published on the subject in May.

The question now is ‘what next’? Mounds of data have been collected over many years, mostly high level data that gives few clues about how people are becoming infected. Data about ‘attitudes’, sexual behavior, economic circumstances, education, etc, have not allowed any useful ‘targeting’ because the usual conclusion is that ‘it is all about sex’ and other kinds of victim blaming. So it’s heartening to hear that data is being collected about blood and injection safety, albeit a very small amount.

The next step needs to involve comprehensive contact tracing, finding out about people’s non-sexual as well as their sexual contacts, visits to health facilities, traditional practitioners, cosmetic providers and anywhere skin-piercing procedures are carried out. If someone is HIV positive it must be asked who, or what did they come into contact with, whether as a result of sexual or any other kind of behavior. Will the deep prejudices of the HIV industry allow them to take these investigations where they need to go, or will the eradication of HIV have to wait until there’s a regime change in the HIV industry?

AIDS, blood, HIV, iatrogenic, nosocomial , , , , ,

Absurd and stigmatizing estimates about how most adults in Malawi get HIV

9 Comments Posted by on May 1, 2014

The WHO and UNAIDS promote their Modes of Transmission model[1] to estimate numbers of HIV infections that adults get from various risks. The model has a simple mistake in its design – causing anyone who uses it to overlook crucial data on HIV in married couples and leading thereby to grossly inflated estimates of numbers of HIV infections acquired from spouses.[2,3]

Several experts recently used WHO’s and UNAIDS’s Modes of Transmission model to identify important risks in Malawi’s HIV epidemic. Their published results[4] provide another illustration of ridiculous, stigmatizing, and anti-family estimates produced by the model. Here’s the gist of what they conclude: Infections from spouses account for 81% of new HIV infections in Malawi (76,688 out of an estimated total of 94,455 infections; see Table).

Simple logic says this is absurd, even without looking at any evidence or data: The number of people getting HIV from their spouses cannot exceed the number of spouses bringing HIV into their families (from any source, such as unsafe health care or non-spousal sex partner). This is logically necessary year-by-year in an epidemic, such as Malawi’s, that has been more or less stable over time. Furthermore, a large percentage of people who are married and HIV-positive die without ever infecting their spouses. So the number of new infections coming from spouses will be much less than half of all new infections.

But that’s not what the model says. Where’s the problem?

The model starts out OK: Using data for 2007, the model finds 2,095,000 married men and 2,497,000 married women (roughly 20% of women were in polygamous marriages).[4] Next, using data from Malawi’s 2004 national Demographic and Health Survey,[5] the model recognizes that more than 10% of married men and women were HIV-positive. So far so good.

But then the model falls off the rails. It assumes that almost all HIV-positive married adults were a risk to infect their spouses. This ignores the well-documented fact that many people who are married and HIV-positive have partners who are also HIV-positive – no one is going to infect anyone in such couples. According to the same 2004 national survey, only 4% of married men in Malawi were at risk to get HIV from their wives (that is, 4% were HIV-negative with an HIV-positive wife), and only 5.7% of married women were at risk to get HIV from their husbands.

Table 1: Estimated number of HIV infections acquired from spouses

Model, risk category for married adults Number of married men Number of married women Model’s estimated number of infections from spouses
Estimates from the Modes of Transmission model (see reference 4)
People who are mutually monogamous 882,000 1,284,000 34,673
Married people who have casual partners 589,000 222,000
People whose spouses have casual partners 222,000 589,000 25,023
Clients of sex worker and wives of such men 388,000 388,000 16,978
 Men who have sex with men and wives of such men 14,000 14,000 14
Total married adults and total estimated infections from spouses according to the Modes of Transmission model 2,095,000 2,497,000 76,688
Alternate estimate recognizing that most HIV-positive married adults have HIV-positive spouses
Total married adults (from Modes of Transmission model) 2,095,000 2,497,000
Married and at risk to get HIV from a spouse (4% of married men, 5.7% of married women; see table12.10 in reference 5) 84,000 142,000
Estimated new infections (assuming a 6.6% annual rate of HIV transmission from wives to husbands and 9.9% from husbands to wives; see reference 2) 5,500 13,500 19,000

Thus, only 226,000 married adults (4% of husbands and 5.7% of wives) were at risk to get HIV from their spouses (see next to last row in the Table). How many of these 226,000 will get HIV from their spouses in a year? During the 1990s, 5 studies in Africa followed discordant couples (only one spouse HIV-positive) to watch HIV transmission from one to the other – distressingly, these studies did not routinely warn participants that they or their partner was infected. With few couples taking care to avoid transmission, 6.6% of HIV-positive wives infected husbands in a year, and 9.5% of HIV-positive husbands infected wives in a year (these rates are from a recent review [2]). With these rates of transmission, 226,000 HIV-positive married men and women in Malawi infected an estimated 19,000 spouses in 2007 – only 20% of the estimated 94,454 new HIV infections in Malawi in 2007.

The Modes of Transmission model’s gross and logically absurd overestimate of numbers of HIV infections from spouses is not harmless. Consider these damaging consequences:

1. Diverting attention from HIV risk in unsafe health care: If sex in marriage accounts for only 20% of new HIV infections instead of 81% as estimated by the Modes of Transmission model, then most infections need to be explained by other risks. What are those other risks? The Modes of Transmission model estimates that all non-spousal sex – casual, commercial, and male-male sex – accounts for a combined total of only 18% of infections. If all sexual risks account for only 38% of infections – 20% from spouses and 18% from other sex partners – what non-sexual risks account for the remaining 62% of infections? The Modes of Transmission model avoids this question by grossly overestimating numbers of HIV infections from spouses.

2. Stigmatizing HIV-positive adults: The estimate produced by the Modes of Transmission model – that sex accounts for more than 99% of HIV infections among adults – stigmatizes all HIV-positive adults with the charge they got it from sex. Publishing such estimates contributes to what could be considered a form of sexual abuse – spouses, relatives, and others accusing people of sexual behavior for which there is no evidence. The estimate coincides with racist stereotypes of sexual behavior, which protect it from critical review.

3. Undermining families: Stigmatizing all HIV-positive adults with the charge they got if from sex breeds suspicion among married adults when one or both learn they and/or their partner are HIV-positive. Lack of trust between spouses weakens families and harms children.

The motivation for such misinformation may be traced to a conflict of interest common among health care professionals – who do not want people to know that unsafe health care contributes to Africa’s HIV epidemics. Rather than admitting the obvious (and doing something about it), health care professionals have been blaming victims, insinuating that almost all African adults with HIV got it from sex. The Modes of Transmission model is part of that stigmatizing and racist smear.

References

1. UNAIDS. Modes of Transmission spreadsheet. Geneva: UNAIDS, 2012. Available at: http://www.unaids.org/en/dataanalysis/datatools/incidencebymodesoftransmission/ (accessed 24 April 2014).

2. Gisselquist D. UNAIDS’ Modes of Transmission model misinforms HIV prevention efforts in Africa’s generalized epidemics. Social Science Research Network, 24 August 2013. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2315554 (accessed 24 April 2014).

3. Gisselquist D. Misinformation from UNAIDS’ flawed Modes of Transmission model. dontgetstuck, 14 September 2013. Available at: https://dontgetstuck.wordpress.com/2013/09/14/misinformation-from-unaids-flawed-modes-of-transmission-model/ (accessed 24 April 2014).

4. Maleta K, Bowie C. Selecting HIV infection prevention interventions in the mature HIV epidemic in Malawi using the mode of transmission model. BMC Health Services Research 2010; 10: 243. Available at: http://www.biomedcentral.com/content/pdf/1472-6963-10-243.pdf (accessed 22 April 2014). At the end of this article, see the link to Additional file 1: Data sources used to populate the Mode of Transmission model – Malawi 2007.

5. ORC Macro. Malawi Demographic and Health Survey 2004. Calverton: ORC Macro, 2005. Available at: http://dhsprogram.com/pubs/pdf/FR175/FR-175-MW04.pdf (accessed 26 April 2014).

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WHO Supports Circumcision Despite What They Know About Injection Safety in Africa?

4 Comments Posted by on April 24, 2014

The World Health Organization’s (WHO) mass male circumcision page states that the operation reduces risk of HIV transmission from females to males (etc), and that they and UNAIDS recommend circumcision as a strategy for HIV prevention, “particularly in settings with high HIV prevalence and low levels of male circumcision”. The claimed maximization of “public health benefit” raises many questions, about compatibility with their current victim blaming and individual responsibility strategy, and also about what can be done in areas with high rates of circumcision and high rates of HIV prevalence (or do they have a policy on foreskin reconstruction?).

But the question I’d like to concentrate on is what WHO means by ‘settings’. If it refers to high HIV prevalence countries, then they must be aware that most HIV epidemics do not follow national or other geographical or political boundaries. Malawi, as mentioned in a previous blog, can be divided into three clusters, two clusters of low HIV prevalence and one of high prevalence. Only the high prevalence cluster has high rates of circumcision. Rwanda, similarly, has three clusters, two of low prevalence and one of high prevalence. Burundi has only one cluster, and that’s the capital city, where most of the country’s HIV positive people reside.

Indeed, high HIV prevalence tends to cluster in cities in most African countries, yet the vast majority of people in most high prevalence countries live in rural areas, where prevalence is often low, sometimes very low. So WHO aims to target up to 80% of males, when most of them can not be said in any useful sense to live in ‘high HIV prevalence settings’. Although HIV epidemics are heterogenous, within as well as between countries, if high prevalence settings refer to anything at all they refer to areas where access to healthcare facilities is high and levels of safety in healthcare facilities are low (for example).

It gets worse because if you look at Burundi and Rwanda’s Demographic and Health surveys (just two examples out of many) you will see that HIV prevalence is higher among Muslim men (mostly circumcised) than men of some of the other (often non-circumcising) denominations; prevalence is lower even among uncircumcised Muslims than circumcised Muslims. Other Demographic and Health Surveys show that HIV prevalence is far higher among Muslim women than among women of other denominations, not just higher than among Muslim men. So, not only does circumcision not always protect men from HIV, it may well have something to do with higher rates of transmission from men to women; this at least merits a bit of investigation, doesn’t it?

What does this have to do with WHO’s (somewhat vague) data on injection safety and healthcare safety, more broadly? Well, in a document on injection safety success stories, the WHO notes that an estimated 25 billion injections are administered annually and that an estimated 70% of them are unnecessary. The report states that “Unsafe practices and the overuse of injections can cause an estimated 32% of Hepatitis B virus, 40% of Hepatitis C virus and 5% of all new HIV (human immunodeficiency virus) infections every single year.” “At least 50% of injections were unsafe in 14 of 19 countries…for which data were available” according to another WHO report.

We don’t know what levels of injection safety are like in WHO ‘priority’ countries for mass male circumcision programs (Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe). But we may assume, in the absence of data, that high HIV prevalence countries also tend to have higher rates of HIV transmission through unsafe injections. So what is the range of ates? 10%? 20%? The rate would be very low in many Western countries, so it must be fairly high in at least some high HIV prevalence countries to average at 5%. But if we are not told how high rates are, and for which countries, how can ‘priority’ countries even weigh the benefits against the risks? How can WHO, for that matter (yet they do claim benefits, up to “3.4 million new HIV infections” to be averted by 2025, not forgetting savings of US$16.5 billion)?

The 20 million figure that WHO recommends to be circumcised only refers to medical circumcisions (and it doesn’t include children or infants, not yet anyhow), not to all those non-medical circumcisions carried out in unsterile conditions. The number of non-medical circumcisions would be many tens of millions, perhaps even over one hundred million over the course of these mass male circumcision programs (another 11 years to go). What if even just 5% of them were to be infected with HIV through unsafe practices? They won’t be receiving injections, presumably, but one would like to think that WHO approved programs would have higher standards of safety than circumcisions performed in unsterile conditions by non-medically qualified people. Alas, it is difficult to estimate rates of HIV infections through unsafe medical and traditional practices because so little effort has ever been made to collect such data.

WHO and UNAIDS are obsessed with sexual behavior, but reluctant to assess non-sexually transmitted HIV, especially via unsafe injections and unsafe healthcare in general. Yet they are willing to promote mass male circumcision programs to reduce HIV transmission when their own figures suggest that the number of people who risk being infected with HIV through these programs is likely to be far higher than even the most outlandish estimates of infections ‘averted’. Far from being a ‘distraction’ from effective HIV prevention, as some have called it, mass male circumcision programs are likely to transmit several times more infections than they could ever hope to avert.

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