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South Africa: With This Kind of Research, Who Needs Ignorance?


Following a recent article about HIV among ‘old’ people in Tanzania which I discussed a short while back, another article has appeared about an increase in HIV among people over 50, this time from Gauteng, South Africa. Prevalence in Gauteng is high, though it is not the highest in the country. The article concentrates, as is customary for articles about HIV, on sexually transmitted HIV, noting ‘unsafe’ sexual behavior, in addition to ‘caring for infected children’.

However the apparent lack of concern older people are said to feel about being infected, along with their ‘ignorance’ which the authors note, may stem from the fact that people in this age group do not engage in as much ‘unsafe’ sex as imagined, that the sex they engage in may not be as ‘unsafe’ as imagined, and that they may face many non-sexual risks as a result of not being informed about these; constant emphasis of sexual transmission and under-emphasis of non-sexual transmission doesn’t help either.

Are the researchers even aware that every skin piercing procedure could be a risk, not just reused injecting and other equipment, but also reused cosmetic instruments (tattooing, piercing, shaving) and reused instruments in traditional practices (traditional medicine, scarification, circumcision)? If older people do not, as the authors suggest, see themselves as being at risk of being infected with HIV, perhaps this is because the non-sexual risks they face through caring for HIV positive people, and risks they face themselves in healthcare, cosmetic and other facilities, have rarely been addressed by HIV intervention programs.

The most worrying aspect of this paper is that it is assumed that sex is the only, or the biggest risk, for HIV. This means that non-sexual risks, which may increase in older people who may have greater healthcare needs, are given so little attention that people do things which they don’t even realize are a risk. Worse still, those providing healthcare, cosmetic and traditional procedures may not realize the risks, or they may be a lot less vigilant in their day to day activities.

Despite the emphasis the authors put on sexual transmission, “using the same needles or sharp objects” was mentioned by at least one of the interviewees. Also, two traditional healers were among those interviewed and seemed aware of their risk to themselves, but not the risk that their clients face, which may be a lot higher. But the use of ‘protective clothing’ by those caring for HIV positive people is far too vague to be of any practical value. What about mentioning skin piercing procedures, needlestick injuries, reuse of needles, syringes, razors and other skin piercing instruments?

This seems to be another missed opportunity to address the substantial non-sexual risks people face from infection with HIV and other bloodborne diseases through skin piercing procedures, whether carried out for medical, cosmetic or traditional reasons. Older people, the subject of this paper, and others around them, may face increased risks from skin piercing procedures, especially those found in health facilities. Instead, the authors obsess about the purported sexual behavior of South African people and fail to make any recommendations about reducing non-sexual HIV transmission.

Why Contact Tracing is Vital in High HIV Prevalence African Countries


A recent blog post I wrote received some comments from ‘Brad’, at The Mosaic Initiative, a grassroots organization based in the US. Although Brad seems to think that what I wrote accords in some way with what he believes, it is quite clear to me that we both think very different things about HIV.

For a start, I believe that HIV epidemics in African countries are NOT like HIV epidemics in the US and other Western countries. The bulk of HIV transmission in Western countries is a result of either male to male sex or injected drug use. The bulk of HIV transmission in African countries is not a result of either of these, in any country.

The very point of the Don’t Get Stuck With HIV website and blog is that no African country has made a convincing estimate of the proportion of HIV transmission that is a result of sexual, as opposed to non-sexual transmission. It is just assumed that about 80% is a result of heterosexual sex and most of the remaining 20% is accounted for by mother to child transmission; these assumptions have been held for more than 20 years and emanate from WHO, the World Bank, UNAIDS and other institutions that control HIV funding, globally and in African countries.

I also disagree with Brad that it is merely “important to know how HIV is spreading”; it is vital to know whether someone was infected through sex, through unsafe healthcare, through some traditional practice or in a tattoo studio. There is no “generalized pandemic” that Brad speaks of. In Western countries, the vast majority of people are not at risk of being infected with HIV. Even in African countries some people are more likely to be infected than others; in Burundi HIV prevalence is low, but in Botswana it is high. In cities, even Bujumbura, prevalence tends to be high.

Prevalence is almost always higher among women than men in high prevalence African countries, higher among employed people than unemployed people, higher among wealthier people than poor people, etc. There is a huge level of heterogeneity, between and within countries. This heterogeneity does not seem to correlate very much with sexual behavior, though you may believe otherwise if you have immersed yourself in HIV industry literature.

For example, birth rates are high in Kenya’s Northeastern Province, condom use is low, education is low, poverty is high, intergenerational marriage and sex rates are high, all things thought to relate to high HIV transmission; but HIV prevalence is the lowest in the country, lower than in some US cities.

The problem with the approach of UNAIDS and others is not that they employ ‘targeting’, as Brad suggests, but that their assumption implies that all sexually active people who engage in heterosexual sex are equally at risk in African countries. You can’t ‘target’ everyone in a population, or even half or a quarter of hundreds of millions of people.

Although UNAIDS and others claim that the bulk of HIV transmission is a result of heterosexual sex between people in long term monogamous relationships, with the implication that one or both partners must have had ‘unsafe’ sex outside of their relationships, they do not carry out contact tracing, that is, investigating ALL the possibilities for how each person was infected.

Most of the emphasis is on sexual transmission, and even then, sexual partners are usually not tested; when they are tested the HIV types are usually not matched. Therefore, it is almost always unknown how each person was infected, even though it is almost always assumed, in the absence of data to prove it, that each infection was a result of ‘unsafe’ heterosexual sex.

Effectively, UNAIDS and others in the HIV industry are not targeting any group because they don’t have a clue where to look. They assume that almost everyone who is HIV positive engages in ‘unsafe’ sex; they also assume that anyone who engages in any kind of sexual activity they consider to be ‘unsafe’ is a ‘risk group’, and that IS every sexually active heterosexual (or heterosexual who has sex with heterosexuals, or whatever nomenclature you care to adopt).

HIV status is not an indication of sexual activity, ‘safe’ or ‘unsafe’; and sexual activity is not an indication of HIV status or HIV ‘risk’. People in the US and other Western countries may object to contact tracing but in African countries it is vital. It has been avoided in African countries precisely because some have decided that it is a ‘bad thing’, that it ‘stigmatizes’ people, but as a result ALL African people in high prevalence countries have been stigmatized. The situation in Africa is not like the situation in Western countries and the sooner the HIV industry realizes that, the better.

Tanzania: HIV Industry Still Failing to Collect Data on Non-Sexual Transmission


One of the many damaging consequences of assuming that HIV is almost always transmitted through usafe sex is that those working with HIV tend not to notice non-sexual transmission, such as through unsafe healthcare, traditional and cosmetic practices. This blog and site is littered with examples of these modes of transmission, and of the HIV industry studiously ignoring every instance of transmission that they can’t explain away as being somehow related to sexual transmission.

High rates of transmission among ‘older’ people, which refers to people who are more than 49 years old (my current age), always comes as a surprise to those working for the industry. The Victorian prudishness that seems to affect people working with HIV means that they believe everyone gives up sex at some arbitrary time in their lives. Bizarre!

But older people, and that means people over 50 in developing countries, where life expectancy is much lower than in Western countries, don’t only continue having sex. They may also require health services more frequently than younger people. While that may not surprise those in the HIV industry, they have had a lot of trouble with the notion that understaffed, underfunded, underequipped health facilities may not be able to provide the safest health services in the world.

Research carried out in Tanzania finds that HIV prevalence among people from 50-98 years was 7.8%, compared to the national figure of 5.1% for people aged 15-49 years. HIV prevalence was higher in urban than rural areas, in common with figures for Tanzania as a whole [note that this is the opposite to what is stated in the abstract but I’m assuming the following text and data are correct]. While prevalence was a very high 12.9% among people 50-59 years old, it dropped to 5.7% among the 60-69 years age group and 3.7% among the 70+ age group.

The two areas for which data was collected, Mufindi and Babati, are in one of the highest (Iringa) and one of the lowest prevalence regions (Manyara), respectively, in mainland Tanzania. Prevalence among 50-98 year olds was 3.7% in Babati and 11.3% in Mufindi. The figure for Mufindi is not so shocking compared to Iringa’s 9.1% prevalence; in contrast, the figure for Babati is more than double the figure for Manyara region, which stands at 1.5%.

But it’s a pity the breakdown for male and female figures for each area is not available. The ratio of female to male prevalence in Iringa is 63%, similar to the national figure of 61%. But the same ratio in Manyara is 11%; there are about 9 HIV positive women for every HIV positive man. Is this shocking ratio maintained among people between 50 and 98 years old?

As is usual with these studies, no data was collected about non-sexual transmission, whether through unsafe healthcare, traditional or cosmetic practices. While the authors conclude that interventions should now target ‘older’ people, they fail to consider non-sexual HIV transmission, which means that some of the most important risk factors will continue to be ignored, and HIV will continue to be transmitted, independent of anything the HIV industry spends its millions on.

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.]

More junk science underestimating HIV from medical injections


AIDS experts still haven’t figured out what is different about Africa that can explain why HIV epidemics there are so much worse than elsewhere. The continuing failure to find what is different exposes persistent (intentional or natural) incompetence on the part of respected researchers.

Specifically, scores of studies that have tested, followed, and retested hundreds of thousands of HIV-negative Africans to find when and how they get HIV have failed to trace the source of observed new infections.[1] Without tracing the source, there is no way to say infections came from sex – but “HIV from sex” is nevertheless the conclusion (and racist slur) from decades of incompetent, incomplete research. When such studies find people with new HIV infections who report no possible sexual exposure to HIV, researchers characteristically reject the evidence: “hmmmm, an African with HIV…must have lied about sexual behavior….”

With that “scientific” method, the US National Institutes of Health and UK’s Medical Research Council could save money by paying researchers sitting in offices in Baltimore, US, or Oxford, UK, to make up data to fit pre-determined conclusions. That would be more efficient than paying them to go to Africa, collect data, and then reject what doesn’t fit desired conclusions.

While funders have avoided funding good science to explain Africa’s HIV epidemics – for 30 years and counting – they have been all too happy to fund junk science that will get the desired results. One popular junk-science strategy to get desired results has been to model Africa’s HIV epidemic with unreliable parameters and weak, selected, or made-up data.

The latest paper by Pepin and colleagues[2] falls into that category of junk science – presenting a model with unreliable parameters and data, and using results from the model to claim that unsafe medical injections accounted for less than 1% of new HIV infections in Africa in 2010 (8,000-16,000 from injections vs. 1.9 million total new infections[3]).

Several obvious problems with the estimate are as follows:

1. Pepin’s assumed rate of HIV transmission through a contaminated syringe or needle – 1 in 150-300 injections – is far too low to allow observed HIV outbreaks through health care in Russia, Romania, Libya, and elsewhere. If those outbreaks occurred – they did! – then Pepin’s proposed rate of HIV transmission through injections is misleadingly low. For example, in Russia in 1988-89 hospital procedures passed from HIV from 1 child to more than 260 children in 15 months. Most transmissions in this outbreak came from children who had been infected less than 6 weeks earlier – enough time for infected children to get dozens but not 150-300 skin-piercing procedures followed by reuse of unsterilized instruments.[4]

2. Pepin’s same model estimates 4,300-8,500 new hepatitis C virus (HCV) infections in Africa from unsafe injections in 2010, less than 1% of estimated new HCV infections (cf: an estimated 18 million Africans were living with HCV in 2005[5], which corresponds to approximately 1 million new infections per year). Because virtually all new HCV infections come from blood, not sex, it’s likely that unsafe injections account for a lot more than 1% of new HCV infections – and by extension, more than 1% of new HIV infections as well. Furthermore, other skin-piercing procedures aside from injections likely account for a lot of new HCV infections – and by extension a lot of new HIV infections as well.

3. Pepin’s estimates distract from facts that need answers. Why do 16%-31% of HIV-positive children in Mozambique, Swaziland, and Uganda, have HIV-negative mothers (among children with tested mothers)?[6] Why do so many mutually monogamous couples find that one or both partners are HIV-positive?

In his conclusion, Pepin commendably recognizes “other modes of iatrogenic transmission” including[2]: “use of multi-dose medication vials, phlebotomies with re-used needles, dental care with improper sterilisation of instruments, unscreened transfusions, ritual scarifications and circumcisions performed by traditional practitioners… Better measurement of such exposures and of their impact on viral dynamics is an essential first step…”

Even so, Pepin does not hit the nail on the head. What is required to measure the “impact [of such procedures] on viral dynamics” is to trace HIV infections to their source. When infections are traced a hospital, dental clinic, tattooist, etc, then continue with outbreak investigations to determine the extent of the damage from unsafe health care or other skin-piercing procedure.

References

1. Gisselquist. Randomized controlled trials for HIV/AIDS prevention in Africa: Untraced infections, unasked questions, and unreported data. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 14 June 2014).

2. Pepin et al. Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010. PLOS one 2014; 9: 1-8. Available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0099677 (accessed 14 June 2014).

3. Annex table 9 in: UNAIDS. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access, progress report 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241502986_eng.pdf?ua=1 (accessed 15 June 2014).

4. See: http://dontgetstuck.org/russia-cases-and-investigations/

5. Hanafiah et al. Global epidemiology of hepatitis C virus infection. Hepatitis 2013. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hep.26141/pdf (accessed 14 June 2014).

6. See pages for Mozambique, Swaziland, and Uganda at: http://dontgetstuck.org/cases-unexpected-hiv-infections/; see also: https://dontgetstuck.wordpress.com/cases-unexpected-hiv-infections/).