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UNAIDS’ Garbage In Garbage Out Strategy Found Fit For Purpose

Although a Journal of the International AIDS Society (JIAS) paper, which ostensibly analyses Modes of Transmission (MoT) data and reports, has been through some kind of peer review process, the term ‘systematic’ in the title is misleading. In fact the review is highly selective. The phenomena of HIV infection through unsafe healthcare, traditional and cosmetic practices have been left out completely. This is despite the ready availability of relevant and up to date papers about these phenomena.

The Don’t Get Stuck With HIV website is a repository for many relevant materials. David Gisselquist also made a paper available last year that they have completely ignored, entitled ‘UNAIDS’ Modes of Transmission Model Misinforms HIV Prevention Efforts in Africa’s Generalized Epidemics‘. The bibliography therein should be very useful for anyone who wishes to carry out a systematic review in the future.

The JIAS study mentions recommendations from a 2012 set of guidelines produced by an MoT ‘study group’ and one of them recommends to “Adopt a bottom-up approach, that is, an approach that ensures that sufficient data is available to parameterize the model before making changes to tailor the MOT to more finely represent the local setting”.

The fact that no data has ever been collected by MoT studies for non-sexual HIV transmission may explain why such modes of transmission are ignored by the JIAS study. But it doesn’t explain why non-sexual transmission receives so little attention in the HIV literature as a whole, aside from peremptory denial of its existence.

Gisselquist recently pointed out some of the most glaring flaws in the MoT methodology in a brief blog post. But even the JIAS paper itself unearths some remaining flaws that make one wonder why such a weak and fragile tool should still be used after about a decade of demonstrations of its uselessness.

Ironically, MoT tools were supposed to contribute to UNAIDS’ ‘Know Your Epidemic, Know Your Response’ strategy. This strategy, like all UNAIDS strategies, is based on the assumption that almost all HIV transmission in African countries is a result of heterosexual transmission. That means that the majority of people in high prevalence countries are said to be ‘at risk’, either of becoming infected or of infecting others. So every African HIV epidemic looks pretty much the same to UNAIDS because of the built in assumptions of their various ‘tools’.

Therefore, a strategy for ‘targeting’ those most at risk ends up not targeting anyone; HIV interventions must aim to cover entire populations. Aside from being a waste of money and time, as well as stigmatizing the most affected populations, UNAIDS have failed to account for the bulk of transmissions in high prevalence countries. The two decade old, phenomenally expensive institution throws up its hands and says that the majority of people at risk of being infected are people who fall into ‘low risk’ categories.

Despite scratching the surface of the Modes of Transmission Model and finding that that’s all there is to it, the JIAS paper concludes that some aspects of it need to be ‘revised’. Which is even more misleading than calling the paper a ‘systematic’ review. But if UNAIDS have achieved anything in the last two decades it is in showing that a garbage in garbage out strategy really does work, and may continue to attract funding for another 20 years, at least. I wonder how many of the authors of the paper will end up working for UNAIDS, if they haven’t already done so.

Did Health Facility User Fees Cut HIV Transmission in 1980-90s Kenya?

Rick Rowden argues that the World Bank was negligent in imposing structural adjustment loans on very poor countries in Africa from the 1980s onwards. He notes that there was little or no evidence at the time that privatizing healthcare would be in any way beneficial in developing countries; on the contrary, the World Bank itself had warned against the introduction of user fees for healthcare in 1980.

After putting tens of millions of people through the disastrous consequences of these untried policies, there is now so much evidence of how damaging they are that even the World Bank agrees user fees are not a good thing. But they have not yet been held accountable, as Rowden argues they should be. Countless numbers of people have suffered and died, health services remain decimated in the worst affected countries to this day; is the World Bank going to try and put right the little that may still be salvaged from the wreckage?

Maybe those in the UK arguing for the imposition of user fees in the National Health Service (NHS) could peruse some of the copious amounts of evidence available showing that such a move will put the health and lives of the poorest and neediest people at risk, while making a handful of wealthy people even wealthier. They can’t use the excuse some would make for the ‘free’ market lunacy of the 1980s, that it was not known what the consequences would be.

But Rowden raises another tantalizing point. He cites one ‘H Stein’ as arguing that the exemption of some preventive services such as vaccinations from user fees, but not curative services, such as STI treatment, “led to the imposition of user fees in STD clinics in places like Kenya in the early 1990s. These fees lowered attendance rates at the worst possible time: the early stages of the HIV/AIDS epidemic in Africa.”

This argument is tantalizing because in the early 1990s HIV transmission among a large cohort of sex workers observed for 20 years had started to decline, and declined fourfold from the 1980s onwards. It is still not clear why HIV transmission declined in this group as members were selected precisely because they were engaging in ‘unsafe’ sex throughout the 20 year period.

Indeed, the national rate of transmission of HIV (incidence) peaked and started to decline in the early to mid 1990s in most parts of the country; it peaked and started to decline long before the government accepted there was a HIV epidemic in Kenya, even before any of the multitude of NGOs turned up to do whatever it is HIV prevention NGOs do (finger-wagging and other variations on that theme).

The authors of a paper on this cohort of sex workers started off their article assuming that HIV transmission is entirely down to sexual behavior. When sex workers who said they always used condoms were found to be HIV positive it was assumed they had ‘overestimated’ condom use. It was assumed that HIV prevalence was at a constant level of 30% among their male clients, although this is likely to be a far more telling overestimation. Other groups among whom HIV prevalence was found to be high were also assumed to have been infected solely through ‘unsafe’ sexual behavior.

It is surprising that risks for non-sexual transmission through, for example, unsafe healthcare (also traditional and cosmetic practices) were never considered for HIV positive people. Facilities were badly run, understaffed, undersupplied and, frankly, dangerous. STI clinics would have been more dangerous still. Why is it that only clients’ sexual risks were considered? Why is that still the case, more than 20 years later?

However, the introduction of user fees and the consequent massive drop in access to STI clinics and other health facilities could have given rise to the observed drop in HIV incidence in the 1990s, which continued into the 2000s. Non-sexual risks for HIV transmission, data for which was never collected, include treatment at an STI clinic, multiple injections, visits to an antenatal clinic, hospitalization, etc.

A 1987 paper by Peter Piot and colleagues finds very high HIV prevalence figures among sex workers, also among men attending STI clinics and women attending antenatal care clinics. But these three groups clearly face the abovementioned risks of being infected with various diseases in health facilities, especially those facilities that are on the brink of collapse; HIV is only one possible healthcare associated infection to which people could have been exposed.

Being a beneficiary of the admirable NHS, I would argue that the service should be further developed as a model for other countries to follow. That is especially true for African countries with very poor healthcare currently, but who, according to the economists who have so far failed miserably to get anything else right, are ‘rising’ economically, riding on a wave of buoyant economies and eye-watering potential for this to continue.

But striving towards universal primary health care is not enough. African countries need safe healthcare, not just any old healthcare. If healthcare access suddenly increases without improvements in safety and infection control, some of the currently declining epidemics may start to increase again. Botswana is an example of a country that decentralized its health services and ended up with one of the worst HIV epidemics in the world, one that is showing little sign of declining right now.

Given continuing high HIV prevalence in wealthier African countries with better access to health services and higher prevalence among wealthier people in urban areas, it is difficult to see Botswana’s experience as mere bad luck. If unsafe healthcare has been a factor in Africa’s worst HIV epidemics then this needs to be thoroughly investigated so that such avoidable transmission is addressed as a matter of urgency. Universal healthcare that is not also safe healthcare will only expose more people to more risks.

[For more about HIV transmission through unsafe healthcare and how to avoid it, see the Don’t Get Stuck With HIV website.]

Namibia: Lack of Healthcare or Lack of Healthcare Safety?

An online Namibian newspaper article reports that “Women who experience violence in volatile abusive relationships face four times higher risk of contracting HIV“, following a study of the links between gender based violence and HIV.

HIV prevalence is currently estimated at 13.4% in Namibia, an upper middle income country with a GDP per capita of $8,191, but also a high level of economic inequality. Population density is one of the lowest in sub-Saharan Africa.

However, when it comes to antenatal care, 81% of deliveries take place in a health facility. The only country I found in the region that was higher than that was South Africa, at 91.4%, which has the highest number of people living with HIV in the world.

81.5% of deliveries are performed by a skilled provider in Namibia. What is probably the highest figure in Africa is that for Botswana, at 99%. But Botswana has the second highest HIV prevalence in the world, at 25%, compared to swaziland’s 26%.

HIV prevalence is higher among women than men in Namibia, at 58% of all infections, and this phenomenon is common to every African country. While domestic and gender based violence need to be addressed regardless of how high or low HIV prevalence is, these are just as abhorrent in rich countries with low HIV prevalence as they are in an upper middle income country with high HIV prevalence.

According to the latest Service Provision Assessment, there are some very serious lapses in infection control in Namibian health facilities, including shortages or unavailability of syringes and needles, soap and water, latex gloves and disinfectant.

So what about addressing safety in health facilities? The number of physicians, nurses and midwives per 10,000 is higher than in other countries in Africa. Some of the biggest differences between Namibia and other much lower prevalence countries is its wealth and it’s far higher levels of access to health services. It is unlikely to be lack of healthcare that results in such high HIV prevalence, but rather lack of safe healthcare.

There is simply no evidence that HIV is ‘mainly driven by heterosexual sex’, the mantra that UNAIDS and the HIV industry have stuck to for so long. Prevalence in Namibia has increased from 1.2% in 1990 to reach a peak of at least 15.3% in 2007, but it has barely fallen since then. It’s time to abandon the sexual behavior fallacy and investigate non-sexual HIV transmission through unsafe healthcare, traditional and cosmetic practices.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don’t Get Stuck With HIV site’s Healthcare Risks for HIV pages.]

HIV Transmission Via Unsafe Medical Injections in Kenya – Significant Risk

Congratulations to Kenya on being one of the first African countries with a serious HIV epidemic to investigate the role of unsafe healthcare and reuse of injecting equipment in transmitting HIV. The study finds that “Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months.

But these findings make the conclusion of the article all the more striking: “Injection preference [my emphasis] may contribute to high rates of injections in Kenya.” If someone is infected with HIV as a result of receiving an injection, then it is the behavior of the health care practitioner that is at fault, not the ‘preference’ of the patient. Health facilities make more money from procedures such as injections than they do from just giving advice or handing out prescriptions, so there may be good reasons why patients ‘prefer’ injections; they may have been led to believe that injections are ‘better’. I’d also be surprised if mere patient preference made much difference to the kind of treatment a patient received in Kenya or elsewhere in East Africa.

Those providing health services need to take responsibility for healthcare associated HIV transmission, and that includes Ministries of Health, professional bodies, and also the WHO, UNAIDS, CDC and other parties who have dominated health and HIV policy in high HIV prevalence countries for decades. Reuse of syringes, needles and other skin piercing equipment carries a very high risk of transmission of HIV, hepatitis and other pathogens. It is not enough to blame patients for their ‘preferences’. Practitioners can decide what treatment a patient needs and what is the best means of administering it, if that means is available to them.

The paper recommends that “community- and facility-based injection safety strategies be integrated in disease prevention programs”. If this is UN-speak for the need to accept that HIV is frequently transmitted through unsafe healthcare and these practices need to stop, then I wholeheartedly agree. This is more than thirty years too late, but it’s good to hear the very mention of non-sexually transmitted HIV in the form of unsafe healthcare being taken seriously in a peer-reviewed journal. I look forward to hearing of other high HIV prevalence countries making the same ‘discovery’ and publicizing it, and also taking steps to reducing such transmission risks.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don’t Get Stuck With HIV site’s Healthcare Risks for HIV pages.]