[This page is condensed from Stopping Bloodborne HIV: Investigating Unexplained Infections, Adonis & Abbey; available for free download at: https://sites.google.com/site/davidgisselquist/stoppingbloodbornehiv.]
Public health managers failed to investigate unexplained HIV infections
The best way to ensure health care does not infect patients is to investigate unexplained infections. No government in sub-Saharan Africa has investigated any unexplained infection by testing other patients to find more victims and to find and fix errors. Similarly, leading international health institutions — World Health Organization, UNAIDS, the US CDC (Centers for Disease Control and Prevention), and others — have not urged investigations. These failures violate the Declaration of Lisbon on the Rights of the Patient: “Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights,” including (article 1) “The right to medical care of good quality.”
Public health managers failed to warn people about risks to get HIV during health care
According to the Declaration of Lisbon on the Rights of the Patients, health care providers and managers are responsible 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.” UNAIDS and WHO know health care is a risk — they warn UN employees working in or visiting Africa that injections, tattoos, and other skin-piercing procedures are risks to get HIV, but to not give similar warnings to Africans. In many African countries, national surveys have found that many hospitals and clinics do not have equipment to sterilize instruments. But neither governments or international and foreign health agencies warn Africans.
Researchers and epidemiologists failed to respect evidence — claiming without evidence that most infections come from sex, and ignoring evidence bloodborne risks are more important
In 1988, WHO experts estimated, without presenting any supporting evidence, that roughly 90% of HIV infections in adults in Africa came from heterosexual sex. That estimate disagreed with evidence available at the time, including: children with unexplained infections, HIV infections more common in people with recent medical injections, and infections not concentrated in sexually more active adults.
How could sex infect so many Africans? A 2006 summary of information from sexual behavior surveys around the world reported a “comparatively high prevalence of multiple partnerships in developed countries, compared with parts of the world with far higher rates of sexually transmitted infections and HIV, such as African countries…”
In 2004, WHO and UNAIDS staff led a team of 15 authors claiming (in The Lancet medical journal): “epidemiological evidence indicates that sexual transmission continues to be by far the major mode of spread of HIV-1 in the [Africa] region.” But the only evidence they presented linking HIV to sexual behavior was the age distribution of HIV-positive Africans. But does that show HIV comes from sex? Other risks change with age. From their late teens, women get more blood exposures from reproduction-related health care and maybe also from cosmetic services. If the ages of those who get HIV is sufficient to show infections come from sex, then by that same argument, tuberculosis and even parking tickets are sexually transmitted.
The meager evidence presented to link HIV to sexual behavior is telling. The 15 authors had between them been involved in dozens of studies in Africa looking at sexual behavior as a risk for HIV infection. The problem for the 15 authors was that the huge body of available evidence on sexual behavior vs. HIV infection disagreed with their claim – adults reporting no partner, one HIV-negative partner, or 100% condom use were getting HIV. As an excuse for ignoring disagreeable evidence, the authors explained “data on sexual behavior are notoriously imprecise.” Of course, many studies show some infections come from sex, but that is not at all the same as showing a majority of infections – much less almost all infections – come from sex.
In the years after WHO’s and UNAIDS’ 2004 defense of the view that sex explains almost all HIV in Africa, a lot of new and unsupportive evidence disagrees. For example, three recent studies — two in Uganda and one in Botswana — collected HIV from large percentages of HIV-positive people in study communities and then looked for people with similar HIV.[6-8] When people have similar HIV, that suggests that one infected the other. The three studies identified sexual partnerships that could explain only 1.8% to 6.6% of the HIV infections they studied in each community. All identified sexual partners with similar HIV were spouses or long-term partners living together. Studies did not ask about and identify short-term partners. Of course, some HIV infections come from short-term partners, but if sex accounted for almost all HIV infections in adults, such partners would have to infect many times more people than long-term partners, which is absurd.
Public health programs stigmatized HIV-positive people with allegation they got HIV from sex
WOMANKIND Worldwide defines sexual bullying to include: “a range of behaviours such as… spreading rumours about someone’s sexuality or sexual experiences they have had or not had…” Public health messages that blame almost all HIV infections on sex, despite evidence to the contrary, are equivalent to malicious and unfounded rumors. Although such public messages are impersonal, they encourage people to think they knew something about the sexual behavior of specific HIV-positive people and to believe and spread similarly unfounded rumors about them.
Why have so many public health professionals failed to warn or protect Africans
Health professionals have not wanted to admit they have been part of the problem. Health program managers want patients to think health care is reliably safe, even when they know that is not so. Once the story that most infections in Africa come from sex got going in the mid-1980s, it has been harder and harder for health professionals to back down — to admit they have known all along that health care infects Africans. Now, with 30% to more than 50% of women in some age groups infected in some African countries, it has become very difficult for health professionals to come clean, to tell the truth. If health professionals are not willing to admit what is happening, then it’s up to people at risk to demand investigations of unexplained infections.
- 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).
2. 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).
3. Chin J, Sato PA, Mann JM. Projections of HIV infections and AIDS cases to the year 2000. Bull World Health Org 1990;68:1–11. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2393014/ (accessed 29 January 2021).
4. Wellings K, Collumbien M, Slaymaker E, et al. Sexual behaviour in context: a global perspective. Lancet 2006; 368: 1706-1728.
5. Schmid GP, Buve A, Mugyenyi P, et al. Transmission of HIV-infection in sub-Saharan Africa and effect of elimination of unsafe injections. Lancet 2004; 363: 482-488. Available at: https://core.ac.uk/reader/11307082?utm_source=linkout (accessed 29 January 2021).
6. Novitsky V, Bussmann H, Okui L, et al. Estimated age and gender profile of individuals missed by a home-based HIV testing and counseling campaign in a Botswana community. J Int AIDS Soc 2015; 18: 19918. Available at: https://dash.harvard.edu/bitstream/handle/1/17295521/4450241.pdf?sequence=1&isAllowed=y (accessed 29 January 2021).
7. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS 2014; 11: e1001610. Available at: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001610 (accessed 29 January 2021).
8. Ratmann O, Grabowski MK, Hall M, et al. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis. Nat Commun 2019; 10: 1411. Available at: https://www.nature.com/articles/s41467-019-09139-4 (accessed 29 January 2021).
9. WOMANKIND Worldwide. Stop sexual bullying: preventing violence, promoting equality, act now. London: WOMANKIND Worldwide, 2010.