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Tag Archives: South Africa

Unsafe Sex and Unsafe Healthcare are Mutually Exclusive HIV Risks in African Countries?

Recently, I blogged about a series of investigations that took place in various US states over a period of 10 years because of 86 cases of hepatitis C infection (HCV) being discovered, which could not be explained by the usual risks for this virus in a wealthy country, namely intravenous drug use and the like.

This extremely comprehensive investigation revealed that the 86 infections resulted from the actions of just six health personnel, who all had an addiction to controlled drugs. Over the course of 10 years they had put the safety of an estimated 30,000 patients at risk.

When a young woman in Brazil was found to be infected with HIV and no obvious sexual risks were established, rigorous research was carried out to discover a possible mode of transmission. The research found that the woman may have been exposed to contaminated manicure instruments many years before.

The manicure instruments belonged to the patient’s cousin, who had been on antiretroviral drugs, but whose treatment had lapsed. Phylogenetic analysis showed that the patient had very likely been infected by this cousin, and that sharing contaminated manicure instruments was the most likely mode of infection.

Worryingly, the paper finds that “In a recent case of transmission among women, the CDC lists, along[side] classical transmission routes, potential alternative sources that must be ruled out, such as tattooing, acupuncture, piercing, the use of shared sex toys between the partners and other persons, and exposure to body fluids, but does not include manicure instruments.”

The use of shared sex toys but not other shared instruments? Forgive me for thinking that people working for the CDC and other normative agencies may have some unresolved issues relating to assumed sexual practices, and perhaps an aversion to discussing non-sexual risks; or maybe that’s just when it relates to African countries?

Although an estimated 70% of HIV positive people live in sub-Saharan Africa, the kinds of investigation that were carried out in the US and Brazil do not appear to have been carried out in any African country. At least, if they have been carried out, they have not been written up in peer-reviewed papers.

Anyone who has visited Kampala in Uganda or Moshi in Tanzania may have seen people with basins of manicure equipment being used in the open, in shops and other premises, on women waiting for buses, working, shopping or just taking some time for a manicure or pedicure.

In Dar es Salaam and other places you may see men shaving another man’s head with a hand held, double edged razor. When one has finished, they swap around. Little nicks and cuts are usually treated with a piece of tissue, or possibly with a bit of antiseptic.

However, when people are diagnosed with HIV in African countries they are generally not asked about their possible non-sexual exposures, through unsafe cosmetic, traditional or healthcare practices. When people say they have not had sex, that they have not had sex with a HIV positive person, or that they have only had protected sex, these matters are generally dismissed.

HIV is not the only pathogen that is possibly fairly frequently transmitted in cosmetic, traditional and healthcare contexts, where skin-piercing is involved. Other pathogens include hepatitis, various bacterial infections, scabies, even ebola. Where skin-piercing is not involved, also, several serious diseases can be transmitted in these environments, for example TB.

It seems that, because it’s Africa, sex is always imputed, even when the patient makes it clear that this may not be, perhaps even cannot be, the mode of transmission. Because it’s Africa, unsafe healthcare, it seems that cosmetic and traditional practices can not explain otherwise inexplicable HIV infections.

According to normative agencies such as UNAIDS, healthcare and other environments are unsafe enough to explain high prevalence of hepatitis C in several low HIV prevalence countries, such as Egypt, but can’t explain high HIV prevalence in a low HCV prevalence country, such as South Africa.

Why should healthcare be unsafe and sexual behavior safe in all and only the countries with high HCV prevalence in Africa, while healthcare is safe and sexual behavior unsafe in all and only the countries with high HIV epidemics? Also, if sexual behavior is so unsafe in sub-Saharan Africa, shouldn’t HCV prevalence also be high all high HIV prevalence countries?

Hepatitis, TB, HIV and Ebola: Healthcare Associated Epidemics?

It is sometimes claimed (by UNAIDS and others) that if HIV was frequently transmitted through unsafe healthcare in sub-Saharan countries, then hepatitis C (HCV) would also be common in the same countries, because HCV is usually transmitted through unsafe healthcare (dental procedures, surgery, stitches, etc). Indeed, HIV prevalence is often higher in countries that have low prevalence of HCV; and the high HCV countries tend to have low HIV prevalence.

However, given that it is well established that both viruses can be transmitted through unsafe healthcare, and that unsafe healthcare practices are probably very common in most (all?) African countries, the non-correlation between HIV and HCV prevalence seems like a very weak and unappealing argument. Because we don’t know the relative contribution of HIV transmission through unsafe healthcare, neither do we know how much transmission is a result of heterosexual sex.

Blaming high rates of HIV transmission almost exclusively on ‘unsafe’ heterosexual behavior has a number of dangerous consequences. For a start, it stigmatizes those who are already infected. It also results in people who don’t engage in ‘unsafe’ sexual practices failing to recognize their risk of being infected. More serious still, it means that public health programs aiming to influence sexual behavior will be relatively ineffective.

HCV prevalence in Egypt is the highest in the world and HIV prevalence is low. But a recent survey concludes that “Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt“. It sounds like measures to reduce transmission have not yet been completely successful. More worryingly, another paper finds that “there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities“.

What about countries where HIV prevalence is extremely high, such as South Africa? HCV prevalence is very low, so the UNAIDS argument above would suggest that unsafe healthcare does not play a significant role in HIV transmission. But does that mean unsafe healthcare is unimportant? After all, resistant strains of TB have been transmitted in hospitals in South Africa and this has even spread beyond South Africa, to surrounding countries, and even to another continent.

In reality, we don’t know that much about HCV in the Africa region. A review of research on the subject concludes that “Africa has the highest WHO estimated regional HCV prevalence (5.3%)” in the world. That’s a striking figure, because HIV prevalence across the whole sub-Saharan African region is also around 5%. There are two serious viral pandemics on the continent that may both be driven to a large extent by unsafe healthcare.

HCV concentrates in certain countries and in parts of certain countries. But so does HIV. Prevalence is relatively low in most of Kenya, for example, only a few percent. It’s high in the two large cities, Nairobi and Mombasa, and highest in three (out of 47) counties around Lake Victoria. The situation in Tanzania is similar, with three high prevalence areas. In Burundi and Rwanda prevalence is also low, except in the capital cities.

So the fact that most high HIV prevalence areas do not overlap much with high HCV prevalence rates is not a very convincing argument that the two viruses are transmitted in completely different ways, the former being mainly transmitted through heterosexual sex and the latter through unsafe healthcare. Comparing HCV and HIV patterns only makes the contention that HIV is mostly sexually transmitted look all the more infantile.

The good news, then, is that improving healthcare safety would reduce transmission of both HCV and HIV, and even a range of other diseases that don’t get anywhere near as much attention as HIV. Good healthcare is also safe healthcare, whereas indifferent healthcare, with low standards of infection control, results in alarmingly high rates of transmission of serious diseases.

Journalists have recently had their attention drawn to the potential drawbacks of neglecting healthcare; ebola is difficult to control in a healthcare environment (as opposed to a rural village, where it appears to die out quite quickly). But it has been shown that it is difficult to control in healthcare facilities because of unsafe practices, such as reuse of skin-piercing instruments, gloves and other disposable supplies, lack of infection control procedures, a shortage of skilled personnel, etc.

One newspaper article even made a connection between ebola and HIV, suggesting that because many West African countries had relatively low HIV epidemics, investment in healthcare was lower, hence the weakness of the response to ebola.

Their analysis is not very perceptive. HIV-related investment in Sierra Leone and Liberia has been high enough to ensure that more than 80% of HIV positive people are provided with antiretroviral treatment. Guinea is way behind them in this respect, with less than 50% of people receving treatment. But spending money on preventing supposedly sexually transmitted HIV, and on treatment, does nothing to address unsafe healthcare.

HCV, HIV, ebola, TB and various other diseases can be transmitted through unsafe healthcare, so this is an argument for strengthening all health facilities in all developing countries. A human right to health does not make any sense if healthcare is so unsafe that patients risk being infected with a deadly disease when they visit a health facility. So ‘strengthening’ healthcare must include making health facilities safer.

It is hardly surprising that people in Guinea, Sierra Leone and Liberia run from health authorities and hide family members who are sick. The prospect of having your house searched by people in hazmat suits, sometimes backed up by people with guns, is frightening enough. But if your property is dragged outside in broad daylight and burned in public, and your sick relatives are hauled off to a ramshackle, understaffed, undersupplied health facility, these must extremely traumatic experiences.

If health facilities are unsafe, healthcare associated transmission of serious diseases will only increase as more people are admitted to them. Transmission rates will not go down until safety is made a priority; this applies as much to HIV as it does to HCV, ebola, TB and other diseases. The additional assurance that people will not be exposed to life-threatening diseases through unsafe healthcare should also increase demand for healthcare.

Healthcare Transmitted HIV: Informed Consent and Conflict of Interest

Research in Mozambique, Swaziland and Kenya has shown that a substantial proportion of HIV positive infants have HIV negative mothers. These infants are likely to have been infected through unsafe healthcare, perhaps reused syringes, needles or other equipment, lack of adherence to infection control procedures, etc.

Amnesty International has launched a campaign to gather information from the public about maternal deaths in Mpumalanga, South Africa. In particular, they are interested in HIV testing, informed consent and whether consent is given voluntarily.

But what kind of ‘information’ are Amnesty collecting? The South African Medical Association’s Ethical and Human Rights Guidelines on HIV and AIDS makes no mention of non-sexual transmission of HIV whatsoever. Is information about the likely source of an infant’s infection not considered to be a vital part of giving informed consent?

Is information about how a mother (or anyone else) may have been infected with HIV not also vital? I would suggest that this information needs to be a standard element in pre- and post-test counselling for everyone, but particularly where the spouse is not HIV positive or where a HIV positive person has no identifiable sexual risks, is not an intravenous drug user, etc.

The Health Professions Council of South Africa’s (HPCSA) Guidelines for Good Practice in Medicine, Dentistry and the Medical Sciences has this to say:

The risk of transmission of HIV infection in the health care area from patient to patient, patient to health care worker, and from health care worker to patient through inoculation of infected blood or other body fluids has been shown scientifically to be very small. Fears, which are not always based on reality, have thus tended to exaggerate the risks out of all proportion.

This paragraph is not backed up by any citations and is expressed in language that is out of place in a set of guidelines for health professions; the word ‘scientifically’ is especially incongruous. What does it matter how small a risk of healthcare transmission of HIV is when an infant is HIV positive and the mother and their partner are not? Adults, also, could face healthcare and other non-sexual risks, but are these risks assessed by practitioners who have been told that they are ‘very small’.

The Mozambique research further shows that some HIV positive mothers were likely to have been infected by their HIV positive infants, that HIV negative mothers with HIV positive infants have not been told how their infants may have been infected, that HIV negative mothers have not been told that they can be infected by their HIV positive infants, that some mothers have been allowed to believe that their infant’s HIV positive status is their fault and that some healthcare workers are unable to answer, or even question, these phenomena.

The HPCSA General Ethical Guidelines for the Health Care Professions lists as one of the duties to patients: “Make sure that their personal beliefs do not prejudice their patients’ health care.” Personal beliefs about how the patient may have been infected with HIV, even beliefs based on the HSPCA Guidelines, should not preclude an unprejudiced assessment of both sexual and non-sexual exposure to HIV.

Amnesty International would do well to consider the possible conflicts between the interests of the healthcare professional and the interests of the patient in regard to providing those being tested for HIV with correct and complete information about how the virus is transmitted. When they have finished in South Africa, they may like to extend their investigation to other African countries.

[The Amnesty International report is discussed further in another blog post, October 10 2014]

Age-disparate relationships do not drive HIV in young women. KwaZulu-Natal, SA

I commented on this back in March when it was reported at a conference. Now the paper has been published (though it is not available free of charge). It concludes: “In this rural KwaZulu-Natal setting with very high HIV incidence, partner age-disparity did not predict HIV acquisition amongst young women. Campaigns to reduce age-disparate sexual relationships may not be a cost-effective use of HIV-prevention resources in this community.”

The HIV industry likes to believe that, although HIV is almost always transmitted through ‘unsafe’ heterosexual sex in African countries, unlike in other countries, it is men’s behavior that is most responsible. This supports their ‘all men are bastards, especially older men, and all women are victims, especially younger women’ mentality.

It’s good timing. After 23 years of monitoring their epidemic in South Africa, HIV experts have seen HIV prevalence increase from less than 1% to almost 30% in that time, and stagnating at over 25% for about the last 10 years. KwaZulu-Natal is the worst affected province, with HIV prevalence in some districts reaching 40% among antenatal clinic attendees.

Perhaps a little less emphasis on sexual behavior and a little more emphasis on non-sexual risks, such as unsafe healthcare, traditional and cosmetic practices, may shed some light on what is driving the epidemic and why efforts to influence HIV transmission in any way seemed to have failed thus far.

[For more about non-sexual HIV transmission via unsafe healthcare, traditional and cosmetic practices, and how to protect yourself from these, have a look at some of our more detailed pages.]

South Africa Continues to Fail to Reduce HIV Transmission

UNAIDS is strange, perhaps stranger than their numerous UN siblings. They have a single disease as their brief and they have spent 20 years learning next to nothing about it. They keep collecting data about sex, because they insist that HIV is almost always transmitted through unsafe sexual behavior in high prevalence African countries, but nowhere else. They have to shore up their arguments by appealing to prejudices, such as popular beliefs about ‘African’ sexuality, the brutish mentality of African men (yes, all of them) and the pathetic victim status of African women.

So it comes as a bit of a shock to them when they accidentally carry out research that casts doubt on their fondly held prejudices. A paper entitled ‘Sexual relationship power is unexpectedly not associated with unprotected sex in tavern populations in South Africa‘ is a case in point. Of course, alcohol abuse is a terrible social problem in South Africa (and many other countries), and needs to be addressed urgently. So is violence against women, gender based crime and a whole host of other social problems that are endemic in countries with a large proportion of very poor people who live in virtually uninhabitable environments.

UNAIDS is almost as old as South Africa’s epidemic, where prevalence stood at less than 1% in 1990 but rose rapidly to more than 25% over a decade ago and has not dropped below that figure since [I should clarify, these figures are for antenatal clinic attendees, not for the male and female 15-49 year old population, among whom prevalence is 18.8%]. The yearly HIV reports that South Africa shoves out are almost entirely about sexual behavior, with next to nothing about non-sexual transmission of HIV, via unsafe healthcare, cosmetic and traditional practices. I wonder how long it will take before anyone notices that they clearly haven’t even started to understand the worst HIV epidemic in the world.

[For more about sexual transmission risks and HIV prevention, have a look at some estimated risks from various sexual practices.]