Bloodborne HIV: Don't Get Stuck!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Simon Collery, David Gisselquist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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