The title above refers to characters in a classic 1939 movie, The Wizard of Oz, based on a 1990 book by L. Frank Baum. In the movie, a tornado picks up a young girl, Dorothy, from rural United States and deposits here in Oz, a magical world with witches and talking beasts. In Oz, Dorothy meets a brainless scarecrow, a cowardly lion, and a heartless tin woodman. Together they follow a yellow brick road to visit the Wizard of Oz. With the Wizard’s help, the scarecrow realizes he can figure things out, the cowardly lion realizes he has courage, and the tin woodman realizes he has a heart. I use the characters in that movie to explain how experts have been mismanaging HIV prevention in Africa.
Brainless scarecrows?
As demonstrated in many countries outside sub-Saharan Africa, the appropriate response to unexplained HIV infections is to investigate to find and stop whatever caused the infections and thereby to protect others. None of the international or foreign public or private organizations or experts focusing on HIV in Africa — all of whom should know that investigating in the appropriate response — have had the “brains” to recommend that response.
The UN’s[1] and UNAIDS'[2] plans to end AIDS in Africa by 2030 focus on sex and injection drug use, ignoring bloodborne transmission. Multiple initiatives to protect young women from HIV focus on sex. Influential computerized models of Africa’s HIV epidemics estimate transmission through sex, with or without injection drug use, and ignore bloodborne transmission.[3] The experts guiding such programs and models disregard evidence that non-sexual transmission is a major — maybe the biggest — contributor to Africa’s epidemics. Evidence includes five recent studies that collected HIV from hundreds of people in a community, then looked for similarities among their HIV to see who infected whom; the studies found similar sequences from pairs of adults (married, or living together) that could explain only 0.3% to 7.5% of HIV-infected adults in each study.
Cowardly lions?
These “oversights” described above are so brazenly obvious that it’s hard to see how the experts involved could have been so genuinely (naturally) ignorant. Maybe not as brainless as they pretended to be. Likely, most are professionally ignorant, cowardly lions acting dumb for money — a sad way to live.
Heartless tin woodmen?
UNAIDS and WHO know health care is a risk — they warn UN employees working in or visiting Africa to beware, BUT DO NOT GIVE SIMILAR WARNINGS TO AFRICANS! In 1991, WHO published a small booklet on AIDS and HIV infection: information for UN employees and their families advising UN employees “living or traveling in areas where the level of medical care is uncertain” to beware and avoid unsafe health care.[4]: “The WHO medical kit contains…disposable syringes and needles in case staff members need to have blood taken or to receive an injection or vaccination… Avoid tattooing and ear piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized.” WHO and UNAIDS revised and reissued the booklet multiple times in subsequent years. The 2004 revision assures special, safe medical care for UN employees[5]: “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new [HIV] infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.”
Where’s the wizard to heal HIV/AIDS experts?
Experts’ and bureaucrats’ failure to do what they trained for and committed to, their failure to protect patients, no doubt hurts them (as well as patients!). Who would want to live that way? I expect the wizard to help them heal will come from the general public — someone who sees one or more unexplained HIV infections in his or her family, talks enlists others in the community to find more unexplained infections, considers their source, and gets the press to take notice. A wizard like that could help one or more local experts to realize what they have known all along, to remember they care, and to discover courage — and having been so healed to recommend or order a government investigation.
Evidence?
These two links (this page; and chapter 6 here) summarize evidence that bloodborne transmission makes an important contribution to Africa’s HIV epidemic. There is enough evidence! Those who say young women can be protected and Africa’s AIDS epidemics can be stopped without addressing bloodborne transmission are either genuinely ignorant (could they be reached?) or professionally ignorant and lying, and thereby insulting people by assuming they are too ignorant to see through his or her lies (and so not worth engaging). Honest arguments could get us all somewhere….
Ethics?
Experts’ failure to ask for or to implement investigations violates the Declaration of Lisbon on the Rights of the Patient (Preamble and Article 1 in [6]): “Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights,” including: “The right to medical care of good quality.” Experts’ failure to warn patients about risks to get HIV from healthcare procedures similarly violates the Declaration’s admonition for health care providers and managers to provide (Article 9) “health education that will assist him/her in making informed choices about personal health and about the available health services.” Not warning people about risks is similarly inconsistent with the Preamble to the Constitution of the World Health Organization: “Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.”[7]
References
1. United Nations General Assembly. 2021. Resolution adopted by the General Assembly 8 June 2021. Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030. A/RES/75/284. Available from: https://www.unaids.org/en/resources/documents/2021/2021_political-declaration-on-hiv-and-aids [cited 21 July 2024].
2. The urgency of now: AIDS at a crossroads. Geneva: UNAIDS, 2024. Available at: https://www.unaids.org/sites/default/files/media_asset/2024-unaids-global-aids-update_en.pdf [cited 22 July 2024].
3. HIV models. HIV modeling consortium, no date [online]. Available at: http://hivmodeling.org/hiv-models (accessed 30 September 2024).
4. Quote from p. 23 in: WHO. AIDS and HIV infection: information for United Nations employees and their families. Doc no. WHO/GPA/DIR/91.9. Geneva: WHO, 1991. This document was formerly available from WHO archives at: http://whqlibdoc.who.int/hq/1991/WHO_GPA_DIR_91.9.pdf (accessed 7 January 2011); however, it is no longer available without specific permission from WHO (according to these procedures; accessed 28 September 2015).
5. Quote from p. 9 in: UNAIDS, Living in a World with HIV and AIDS: Information for employees of the UN system and their families. Doc no: UNAIDS/04.27E, English original, May 2004.
6. World Medical Association (WMA). WMA Declaration of Lisbon on the Rights of the Patient, revised 2005, reaffirmed 2015. Ferney- Voltaire: WMA, 2015. Available at: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ (accessed 29 January 2021).
7. WHO. Constitution of the World Health Organization, in: Basic documents, 45th ed, suppl. Geneva: WHO, 2006. Available at: https://apps.who.int/gb/bd/pdf_files/BD_49th-en.pdf (accessed 29 January 2021).
Bloodborne HIV: Don't Get Stuck! 