Sunday, December 28, 2014
The ongoing inquiry into an outbreak of HIV in several Cambodian villages has so far found more than 160 cases. Most cases were found in one village, but 20 were found in a nearby village and a few more in a third.
However, the inquiry needs to be expanded to include all villages where such an outbreak may have occurred. It also needs to be expanded beyond unlicensed premises and practitioners. It should include all health facilities, pharmacies, practices and anywhere skin piercing procedures take place.
The reason the inquiry needs to be so broad is that anyone in the country may be as ignorant as their esteemed leader, Hun Sen, about the risk of being infected with HIV through unsafe healthcare. Many people may only have heard about sexual risk; those who have heard about non-sexual risks have probably heard that it is very unlikely, which is the received view propagated by UNAIDS, WHO, CDC and the like.
Also, the CDC estimates for the risk of being infected through reused injecting equipment seem unbelievably low. They claim that the risk from needle-sharing during injection drug use is 63 in 10,000. The one unlicensed practitioner arrested so far has admitted to reusing syringes and needles, so the risk may be similar to that faced by injection drug users. But compare those CDC figures to estimates on the Don't Get Stuck With HIV site.
If the risk is as low as CDC's 63 in 10,000 then this single unlicensed practitioner must have an impossibly large number of clients, who receive a lot of treatment that involves skin piercing of some kind. It is far more likely that other practitioners, licensed and unlicensed, also take risks. Yet, infections will only be brought to light if the investigation is broad and thorough enough.
The investigation also needs to report honestly. Hun Sen may wish to protect his country's image of one that has avoided a very serious HIV epidemic; UNAIDS may wish to continue denying non-sexual transmission through unsafe healthcare; CDC may not want to review their estimated risk, for whatever reasons, etc.
But the most important thing is to discover how people have been infected, then cut off these routes to infection. This kind of outbreak could happen again and again, because neither practitioners nor members of the public are being warned of the risks of infection through reused medical instruments and other unsafe practices.
The investigation so far has demonstrated one of the dangers of the sort of culture of blame that has been developed by UNAIDS and the HIV industry. If those found to be engaged in unsafe practices are persecuted, threatened, imprisoned or otherwise punished, the investigation is unlikely to bring too many outbreaks and unsafe practices to light.
Those already infected need to be identified, and given treatment and support. Those at risk, likely to be a very large number of people, need to be proteted from harm.
The arrest of a single practitioner to date looks like a case of scapegoating, somewhat resembling Libya's reaction when an outbreak was discovered there, or the Ugandan nurse sentenced to several years in prison for 'negligence' because she is said to have risked infecting an infant with HIV (she was released after serving nearly one year but the conviction was upheld).
Condemnation of those engaging in unsafe practices, when the HIV industry itself has failed to warn practitioners and patients about the risks, is entirely misplaced. It only adds to a systematic failure to protect people from being infected, as well as exposing health practitioners and others to abuse and accusations of 'deliberate' transmission of HIV.
Posted by Simon at 1:07 PM
Saturday, December 20, 2014
Prime Minister Hun Sen of Cambodia is probably not the only national leader totally confused about HIV/AIDS. The news that over 100 people may have been infected with HIV as a result of an "unlicensed" doctor reusing skin piercing equipment, such as syringes, needles, intravenous drips and possibly others, underlined the leader's complete ignorance about HIV transmission.
The prime ministers first response was to doubt if the HIV tests were accurate. But he seems to believe that HIV is exclusively transmitted through sex (and perhaps from mother to child or through injecting drug use). He doesn't seem aware of transmission through blood exposure as a result of unsafe health, cosmetic or traditional practices. He also seems to believe that the quack arrested for performing these unsafe procedures must himself have been infected with HIV, which is not the case.
If one of the quack's patients was HIV positive, reusing equipment that pierces the skin, or even is inserted into the mouth or other orifices, runs the risk of transmitting HIV and various other pathogens.
It wasn't that long ago that Cambodia was predicted to be the first country to eliminate HIV transmission altogether, perhaps in the next few years. The epidemic is very small there and most transmission is likely to be through male to male sex and intravenous drug use.
But the outbreak in Roka Commune, Battambang Province shows that there are other risks. This kind of outbreak is likely to have happened many times in many countries over the past few decades. What makes this outbreak different is that it was noticed and (hopefully) investigated. Many quacks, perhaps even legitimate healthcare practitioners, may be reusing equipment, completely unaware that this could be exposing their patients to HIV, hepatitis and other bloodborne diseases.
A survey in Kenya and several other African countries found that people who have had injections in the past 12 months are far more likely to be HIV positive than those who have not. Babies in Mozambique and Swaziland have been found to be infected with HIV even though their mothers are negative (or the mothers have been infected by their babies). Women who only have sex with other women, which is extremely low risk, have been infected.
But in African countries this kind of outbreak remains uninvestigated. The women in Mozambique have never been told how their babies may have been infected, and have been allowed to believe that it was their (the mother's) fault. The women who have sex only with other women have been told that such sexual behavior must be, after all, risky. And the many people who have probably been infected through unsafe healthcare have never been given any explanation.
So it's not surprising that PM Hun Sen doesn't believe the results: he, like most people in most countries, rarely hear anything about non-sexual transmission of HIV, through unsafe healthcare, cosmetic and traditional practices. This is in a country where healthcare conditions are poor and a lot of people resort to self medication, quacks or other people with few or no healthcare skills.
Hun Sen asks if an 80 year old person or a child are likely to be infected with HIV; and the answer is yes, anyone can be infected through any skin piercing practice where the equipment is reused and conditions are unsterile. They are also likely to be infected with hepatitis and any other bloodborne pathogen that is going around. Hospitals, dental surgeries, tattoo parlors, hairdressers and many other settings may be similarly risky.
So it's time for UNAIDS and the WHO to come clean, because if national leaders are so confused about HIV modes of transmission, how clear can members of the public be? If we are constantly bombarded with misleading statements about sexual risks, but rarely told about serious non-sexual risks, everyone could be as confused as the Cambodian Prime Minister.
Posted by Simon at 4:33 PM
Friday, December 5, 2014
In a paper entitled 'Religious and Cultural Traits in HIV/AIDS Epidemics in Sub-Saharan Africa', the authors conclude that the Islamic faith is protective against HIV. Their conclusions about the role of colonial powers is not quite so clear, except to the extent that former British colonies (FBC) tend to be predominantly Protestant (or non-Catholic) and most of the countries that are predominantly Catholic are former non-British colonies (FNBC).
Making associations between HIV and religion, high prevalence and Christianity, low prevalence and Islam, high prevalence and FBCs, lower prevalence and FNBCs, etc, are very tempting. All the predominantly Muslim countries in Africa have low HIV prevalence, with Guinea-Bissau (3.9%) being the only one with a figure higher than 2% (and it is only 45% Muslim). Prevalence in countries with 90% or more Muslims only reaches a high of 1.1% in Sudan.
All the countries with prevalence above 4% are predominantly Christian; out of these, only four are FNBCs. There are nine countries with over 1 million people living with HIV. Only one is an FNBC (Mozambique) and only one is roughly evenly split into Christians and Muslims (Nigeria). All the highest prevalence figures are in the Christian dominated Southern region, and the four with prevalence below .4% are in the predominantly Muslim North.
But things come apart a bit when you look at countries that are Christian, but not predominantly Protestant. There are six predominantly Catholic countries, all FNBCs, where the highest prevalence figure is 2.9%; all these countries are in Central Africa. Yet, a number of countries made up of between 20% and almost 50% Catholic populations have some of the highest prevalence figures, too.
While Muslims and Catholics (ostensibly) oppose extra-marital sex, homosexuality and various other phenomena, so do Protestants and other non-Catholic Christian churches. Suggesting that such opposition is stronger or more active in countries with lower HIV prevalence risks arguing in a circle.
Some useful generalizations can be made, such as very high prevalence in Southern Africa, very low prevalence in North Africa, mainly low prevalence in West and Central Africa and high prevalence in East Africa. It is also broadly true that most predominantly Christian FBCs are Protestant dominated, rather than Catholic dominated. With the exception of Mozambique, prevalence in all FNBCs is never higher than 5%; but these countries can be predominantly Muslim, Christian, mixed, or Catholic.
There are two major objections to the analysis given or implied in this paper. The first is is that patterns and generalizations that can be made at the regional level, or even at the country level, do not always hold within countries; the second objection is to the assumption that HIV is almost always sexually transmitted.
The authors find some broad correlations but they do not discuss causality. They claim that the populations of countries such as Egypt, Tunisia and Algeria, for example, were protected from HIV because of their Muslim faith and the practices that go with that. But those countries, and others in the North, might have been 'protected' by one of the largest desert areas in the world, the Sahara.
In addition, HIV in those countries is mainly subtype B, which is generally associated with male to male sex (and to a lesser extent injected drug use). Subtype B is rare in other parts of Africa, with the exception of South Africa (where it mainly seems to infect men who have sex with men). HIV epidemics appear to form different patterns across regions and countries. But it also forms different patterns within countries.
High HIV prevalence in the Southern region may be facilitated, to some extent at least, by the well developed infrastructure there, infrastructure that would have been built by the British Colonial power. The same colonial power built far fewer roads or other infrastructure in East Africa, and none at all in Central Africa, where they had very little control.
However, they had control of a number of West African countries, where there is generally a strong infrastructure. Why did HIV not spread around West Africa to the extent it did in Southern Africa? Well developed infrastructure may partly explain variation in HIV prevalence between some countries and some regions, but it doesn't explain enough. There are clearly factors operating within each country that account for some variation in HIV prevalence.
Regarding the second objection, the authors link the Muslim faith with certain moral precepts which they feel protect people from HIV. However, the majority of people in non-Muslim countries were not infected because they engaged in 'immoral' behavior. Even 'official' figures show that the bulk of people infected in many high prevalence countries have only one sexual partner, and most of those partners are HIV negative.
The 'promiscuous African' stereotype can not be used to explain HIV transmission because it is a prejudice, not an empirical fact about people with HIV, or about people from countries with high HIV prevalence. But similarly, the 'non-promiscuous Muslim' is also a stereotype, however positive. If you can not discern a person's sexual behavior from their HIV status, nor discern a person's HIV status from their sexual behavior, the conclusion that being a Muslim is protective against HIV is unwarranted.
Religion and former colonial power may be two important influences in HIV epidemics, but the authors fail to show convincingly how they operate on HIV transmission. Arguing that those and all other relevant factors relate exclusively to indivicual sexual behavior fails to explain the spread of HIV within countries. Heterogeneity between and within African countries suggests that HIV prevalence is not all about sex, and that not all factors operate at the individual level.
Monday, November 17, 2014
In developing countries "the risk for maternal death during childbirth can be as high as 1 in 15". One might expect this horrifying statistic to be used as an argument for adequate and safe maternal healthcare. Instead, it is being used to sell Depo Provera hormonal contraceptive for Pfizer, administered via a device claimed to be 'innovative'.
The device in question, the 'Sayana Press', may reduce the risks of needles and syringes being reused, and (hopefully) of single doses being split between two people. But calling something 'innovative' does not guarantee its safety, and the hope is that the drug can also be self-administered, in addition to being administered by community based health teams.
However, Depo Provera has been found to double the risk of HIV negative women being infected with the virus through sex with an infected partner, and double the risk of HIV positive women transmitting it to a HIV negative sexual partner. In the case of Depo Provera, population control, reducing the number of births in developing countries, is being prioritized over protecting women from being infected with and with transmitting HIV.
The citation above from one of PATH's blogs starts off talking about the long walk some women have to 'access' contraception, the long queue they have to wait in, the use of a smaller needle, etc. But dressing this up as an exercise in 'enabling' women or genuine service provision is pure humbug.
The Don't Get Stuck with HIV Collective is in favor of access to healthcare, especially reproductive healthcare, as long as that healthcare is safe. Depo Provera is not safe. The World Health Organization has accepted that it is not safe, but has decided that reducing birth is more important than safety, and even than reducing HIV transmission.
The blog goes on about reaching women in remote areas. Women in remote areas are far less likely to be infected with HIV than women in urban areas, or women living close to major roads, health facilities and other modern amenities. But the use of Depo Provera may be the very factor that increases risk under such circumstances.
'Getting health services out to people' is only desirable when those health services are safe. True, many women want to limit the size of their families, presumably many men do, too. But giving people options must include knowledge about healthcare safety and awareness about non-sexual risks from unsafe healthcare, dangerous pharmaceutical products like Depo Provera, and even the many vested interests that various parties in the population control bruderbond may prefer to keep to themselves.
Insidious use of words like 'innovative', 'community', 'village' and the like are great when raising funds or carrying out PR activities, but it doesn't get away from the fact that, in the case of a dangerous drug like Depo Provera, it is not the method of delivery that presents the increased risk of HIV transmission, but the drug itself.
Healthcare is a human right, and an inherently good thing; but unsafe healthcare is the complete opposite of what people in developing countries with serious HIV (also hepatitis, TB, ebola, MRSA, etc) epidemics need. Depo Provera has been found to be unsafe. Creating demand for it, therefore, is not in the interest of people living in poor countries; it only benefits Pfizer, and the many organizations and institutions that have been attracted to the potential funding it represents.
Wednesday, November 12, 2014
I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”
The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.
You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.
‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.
So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.
The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.
The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.
The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.
Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?
Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.
The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.
To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.
Monday, November 10, 2014
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?
Thursday, November 6, 2014
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 risk.
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 heterosexual sexually transmitted HIV contention 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 receiving 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.
Saturday, October 25, 2014
The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.
It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.
But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.
In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don't Get Stuck With HIV site.)
The act makes no explicit mention of non-sexual transmission through cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.
The above incidents raise questions about the act's definition of 'informed consent', which requires that people be given "adequate information including risks and benefits of and alternatives to the proposed intervention". Were mothers informed about all of the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?
Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.
The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.
Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn't always protect them from conviction.
Part one of section 45 reads: "All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification"; part three reads: "A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction...".
So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.
Friday, October 17, 2014
When Peter Piot, the 'Virus Detective Who Discovered Ebola', went to one of the first identified outbreaks in 1976 in the Democratic Republic of Congo, he reported that "it was clear that the outbreak was closely related to areas served by the local hospital".
Piot says: "The team found that more women than men caught the disease and particularly women between 18 and 30 years old - it turned out that many of the women in this age group were pregnant and many had attended an antenatal clinic at the hospital."
He goes on: "The team then discovered that the women who attended the antenatal clinic all received a routine injection. Each morning, just five syringes would be distributed, the needles would be reused and so the virus was spread between the patients."
What he has to say about people getting ill after attending funerals is repeated in contemporary reports on ebola in West Africa, ad nauseam. But the comments about visits to the hospital, women attending antenatal care and reuse of syringes (and possibly other medical instruments) are no longer mentioned so much.
The CDC does write that ebola "has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment", but they are not as expansive as Piot about exactly what that means on the ground.
There was a whole rash of recent reports about women being more likely to be infected with ebola than men in the current outbreak and a rather narrow set of speculative explanations about why this might be so, one being that women are more likely to be involved in giving care than men.
While women may well more often be the 'caregivers', an article in the New England Journal of Medicine summarizes available data on every reported case. However, it finds that there is very little difference in the numbers of men and women infected, and even the number of men who die from ebola.
There are also far fewer children infected than adults, despite claims that 'women and children' are more likely to be infected than men.
As far as I can see, media speculation into why women may be more likely to be infected than men (because they may have been more likely in some instances) did not question the possibility that women are often more likely to access healthcare, especially when pregnant.
Piot makes this connection during the first investigated ebola epidemic and goes on to connect women's elevated risk with the use of unsterile syringes, not just casual contact in healthcare facilities.
It is to be hoped that clinics are no longer issued with five syringes a day, though clear data about supplies of syringes and needles is hard to come by. But what about other infection control equipment and supplies; especially equipment and supplies in facilities that are experiencing extreme shortages?
What about facilities that are understaffed, where an adequate number of workers may be able to take certain precautions to protect themselves and their patients, but an inadequate number may only be able to think about their own safety, or not even that?
In the case of HIV there are many reasons why a woman might be more likely to be infected through unsafe healthcare. They are expected to attend antenatal care during pregnancy, give birth in a health facility, attend post-natal care, and perhaps several other reasons.
But since western countries, especially the US, have started taking an interest in ebola, they have reinforced efforts to round up people who look in the least bit like they have a fever and sticking them in an already overcrowded health facility, where conditions are appalling.
So if women were more likely to be infected with ebola earlier on in the current epidemic, and in some of the earlier outbreaks in other parts of Africa, perhaps the current approach is influencing the gender balance somewhat. One result possibly being that men are no longer less likely than women to go to a health facility (especially if they are given no option).
Piot says: "The closure of the hospital, the use of quarantine and making sure the community had all the necessary information eventually brought an end to the epidemic - but nearly 300 people died." Most people were quarantined in their own homes, not in an overcrowded and filthy ward.
How things have changed. Far from trying to persuade people to stay in their homes and supporting family members to look after them, US soldiers are helping to send people to what could be the very epicenter of the epidemic.
There are now far more confirmed and suspected ebola cases than there is hospital capacity to care for them. So a strategy that aims to strengthen and make hospitals safer, in combination with strengthening communities to care for people at home might now be the only option left.
Wednesday, October 15, 2014
My last post cited an article from the English Guardian claiming that a two year old boy had been bitten by a fruit bat and thus became 'patient zero' for the current ebola epidemic in West Africa. Since then, the newspaper has rewritten the paragraph to read:
"In December last year, near the village of Meliandou in southern Guinea, two-year-old Emile may have come into contact with one of the fruit bats that fly through west Africa’s skies, often gathering at dusk to roost in trees."
'May have come into contact with' is a lot better than what Clar Ni Chonghaile wrote previously, but the article still confidently claims that this two year old boy is 'patient zero'. An article in the New England Journal of Medicine shows that this confidence is mislpaced:
"Potential reservoirs of [ebola], fruit bats [...] are present in large parts of West Africa. Therefore, it is possible that [ebola] has circulated undetected in this region for some time. The emergence of the virus in Guinea highlights the risk of [ebola] outbreaks in the whole West African subregion."
An infectious disease doctor at CDC goes further: [these] two kids were likely early cases of the outbreak but not the first cases.
My criticism of Ni Chonghaile is not that she is wrong about bats or patient zero, but that she infers some kind of certainty where there are at best hypotheses, and at worst pure speculation. I accept fully that epidemiology is often like that, therefore I object to the use of 'fruit bats' and 'funeral practices' as explanations when these are probably a very small part of the story.
Although it is not my purpose to check 'facts' in the article, I would also say that timing is very important; it matters a great deal when the first suspected case was reported, whether they survived, when the next case was reported, etc. So it is worth pointing out that Ni Chonghaile also gets the dates wrong: the symptoms started for the first suspected case on December 2, not December 26; he died four days later.
But the most important thing that Ni Chonghaile and others writing on the subject fail to discuss is the possibility that unsafe healthcare is likely to have played a considerable role in transmitting ebola. Infection from healthcare worker to patient, as well as from patient to healthcare worker, are very likely, so is infection from patient to patient. What about reused syringes, needles and other equipment? Even reused gloves?
Naturally, the Guardian and other media outlets decry conditions in health facilities in African countries in the abstract. But concrete evidence that unsafe healthcare may have been responsible for transmitting HIV, hepatitis, TB and other diseases in the past, and may still be responsible, doesn't seem to impinge very much on their ostensibly enlightened consciousness.
Eliminating contact with bats, funeral rites and a handful of other exotic phenomena will not, have not, stopped the epidemic. Sure, a bat (or some other animal) may have started the current outbreak, but how has it been sustained since then (whenever that may have happened)? This is not at all about blame, but about tracing how each infection occurred and eliminating that mode of transmission.
These trivial 'certainties' deflect attention from a host of uncertainties, but also from the unspoken suspicion that the current approach itself is not working, that protocols may be incomplete, that the proposed solution may be part of the problem. It should not be beyond a journalist to question things that seem to be relevant, but are currently being ignored. Or perhaps I expect too much from them?
Monday, October 13, 2014
The English Guardian reports: "In December last year, near the village of Meliandou in southern Guinea, two-year-old Emile was bitten by one of the fruit bats that fly through west Africa’s skies, often gathering at dusk to roost in trees." In fact, as the article goes on to make (partially) clear, this is just one hypothesis out of many.
The 'first' person infected in the current outbreak may or may not have come into direct contact with a bat, or some other animal; or the outbreak may have occurred in a health facility, rather than in 'the bush'; the term 'Patient Zero' is suitably dramatic for articles about disasters set in exotic locations, but has distracted attention from how people continue to be infected with ebola.
It's comforting to think that African two year olds are a lot less likely to be bitten by bats now that the scientists, medics and disaster workers have moved in; perhaps African parents will even give up or modify their unsafe bat-hunting habits and take people to hospital if they are thought to be sick, and cease to take vaguely defined risks of being infected at funerals.
Meanwhile, when a healthcare worker in Texas is infected with ebola, being one of the many people who nursed ebola victim Thomas Duncan, a 'breach of protocol' is immediately suspected. Another hypothesis, of course (although it leaves out the possibility that the protocol has failed to take into account some additional mode of transmission).
Compare this to an earlier blog post: when 86 people who have no identifiable risks for the virus are infected with hepatitis C in the US, expensive investigations are carried out into possible breaches of infection control processes in the health facilities that the victims attended.
Yet, when millions of Africans who have no identifiable risks for the virus are infected with HIV, an entire industry develops around the prejudiced view that Africans engage in huge amounts of unsafe sex. No investigations are carried out into conditions in health facilities, although various reports show that infection control processes are seriously lacking.
Of course, there was no ebola protocol in West Africa back in December of last year. But all the more reason, then, to investigate health facilities. What kind of infection control processes were in place then, and are now? Subsequent findings suggest that there are severe shortages in trained personnel, supplies and beds, etc, similar to those noted in other African countries.
Rational explanations in western countries, but metaphors and non-rational backstories in Africa. Spacesuits, because it is an exotic virus from a different planet, brave westerners, but only poor and uneducated Africans.
It just seems a bit suspicious that ebola (and HIV and other diseases) are spread through the ignorance and carelessness of victims in African countries, but through a 'breach of protocol' in the US. Health facilities are such dangerous places in African countries that it is surprising authorities insisted on rounding up those suspected of being infected with ebola and marching them off to a clinic in the first place.
But that approach may now be challenged if this article in the New York Times is at all correct. It says that officials have admitted defeat and that they are going to "help families tend to patients at home". About time too. This could be a major turning point if it is taken to its logical conclusion (if logic if given a role, for a change).
As David Gisselquist has pointed out on this site, people are not being asked about possible infection through through healthcare procedures they may have received in the recent past. Gisselquist has been arguing that people should be warned about healthcare risks, treated with respect and fully supported if they decide to care for ebola patients at home.
Long before the current ebola outbreak occurred it was already common practice for healthcare professionals to say as little as possible about lack of safety in facilities, resulting in HIV, hepatitis, TB and other diseases being transmitted through various procedures, such as injections with reused syringes and needles, unsterilized equipment, reused gloves and other materials. This needs to change, as the ebola outbreak shows (and as the hepatitis and HIV epidemics have been demonstrating for several decades).
In the US there are possible insurance claims, professional negligence inquiries, outbreak investigations, protocols to be rewritten, with some of these phenomena possibly being mentioned in the mainstream media from time to time. Oh, and perhaps some much loved mongrels to be euthanized.
But in Africa the media will continue with its customary approach: treat the people as an exotic, primitive species, to be pitied for their funeral practices and 'bush meat' hunting, their reluctance to go to a hospital (implied to reflect a suspicion of modern or 'western' things or people), etc. There will be lots more 'ebola orphans', two year old Emiles, ministering angels in spacesuits and the like.
It's as if this completely unforseeable 'perfect storm' (a metaphor also favored by the media when writing about HIV) took away Patient Zero, and the rest of the outbreak was down to a combination of other ineluctable processes. But, whereas a perfect storm is a rare combination of factors, unsafe healthcare has been around for decades.
The current ebola outbreak is a symptom of decades of unsafe healthcare; it is nothing like a 'perfect storm'. Two year old Emile, ebola's putative patient zero, is as far from being the index case as Gaëtan Dugas was for the HIV epidemic. Stopping ebola requires an admission that unsafe healthcare spreads disease and allows isolated outbreaks to become pandemics. Apologies if the truth is far too prosaic to sell newspapers.
Friday, October 10, 2014
When I was writing yesterday's blog post I didn't realize that the Amnesty International report I referred to had already been published. It's called 'Struggle for Maternal Health: Barriers to Antenatal Care in South Africa'. It is quite extraordinary that such a lengthy report about maternal health can fail to mention safety, unsafe healthcare, healthcare transmitted infections and the like.
But the report puts the cards on the table on page 21: "Heterosexual sexual intercourse is the main cause of HIV transmission in South Africa." The South African 'National Strategic Plan' is cited in support of this contention, and that document doesn't really support the claim at all, although it's clear that it comes from the usual documents from the usual normative agencies.
Normative agencies such as UNAIDS, WHO and others make guesstimates of the proportion of HIV transmission that can be attributed to male to male sex, intravenous drug use, commercial sex work and various heterosexual 'groups' (who are never very clearly defined). The minute figure that remains, 1-2%, is attributed to healthcare transmission of HIV.
But as yesterday's blog (and other data on the Don't Get Stuck With HIV site and blog) show, there are numerous types of healthcare transmission of HIV, including antenatal care, invasive forms of contraception, blood tests, donations and transfusions, child delivery, injections, surgery and many others.
Amnesty and others go on about stigma, the need for privacy, lack of information and poor public transport for pregnant women. But the stigma is not very surprising: if a HIV negative man constantly hears that the virus is primarily transmitted through heterosexual sex and that his wife is HIV positive, or that his child is, he is not being irrational in believing that his wife has been having sex with someone else.
Rather, he is misinformed. Misinformed by the likes of UNAIDS, WHO and, it seems, Amnesty International. Neither the woman nor the man are told that HIV may have been transmitted through some non-sexual route, perhaps even through unsafe healthcare. This is an especially important mode of transmission in the case of HIV positive infants whose mothers are negative, or HIV positive mothers whose partners are negative.
The closest Amnesty International's report gets to the issue of unsafe healthcare is where they recommend "[paying] particular attention to the need to develop, resource and implement programmes to address the underlying determinants of health that promote safe pregnancies and deliveries." [my italics] But there is little or nothing in the body of the report indicating that unsafe healthcare may be an underlying determinant in much of the morbidity and mortality among women, infants and children.
The report does talk to healthcare users and providers and there are some useful findings. People are not given clear, complete or even accurate information a lot of the time. Healthcare workers often lie or withhold vital information and they may even be ignorant of certain matters themselves.
Antenatal care provision may be lacking in South Africa, but the country has one of the highest figures for women giving birth in a health facility among all the high HIV prevalence African countries. It also has one of the highest figures for deliveries being attended by a skilled health provider.
In other words, high HIV prevalence countries tend to be those with better antenatal care indicators, rather than worse. Amnesty also reports on transport, but transport infrastructure is more developed in SA and other high HIV prevalence countries than it is in East and central Africa, where HIV prevalence is also lower.
Amnesty International did not seem to question these phenomena, despite the fact that they have noticed that HIV prevalence is high in SA, especially in the areas they did their research (KwaZulu Natal and Mpumalanga), also that maternal morbidity and mortality are much higher among HIV positive than HIV negative women.
Had they questioned the often cited but never demonstrated reflex 'heterosexual intercourse is the main cause of HIV transmission', they might also have tried to find out if health professionals may be hiding behind patient confidentiality and privacy and deliberately avoiding testing partners of HIV positive women because they wouldn't want anyone to suspect that unsafe healthcare can be responsible for transmitting HIV.
These both look like conflicts of interest for healthcare providers, between informing HIV positive people how they or those they care for may have been infected and avoiding the suspicion that unsafe healthcare can result in transmission of HIV, hepatitis, bacterial infections and other pathogens (including TB, ebola and anything else going around in hospitals).
South African's constitution holds that healthcare should be of 'good quality' and that citizens have the right to the highest attainable standard of health. Unless health facilities are safe places, increasing access to healthcare may be counterproductive and expose people to avoidable illness and injury. Unless healthcare personnel are enabled to provide safe healthcare, training and retraining them may be similarly counterproductive.
A well funded and experienced human rights NGO such as Amnesty International must go beyond the corporate mythmaking of normative agencies, the views of people constantly bombarded with misinformation and prejudice about HIV transmission, and health professionals who are either ignorant about healthcare transmission or who wish to protect their profession from suspicion of infecting patients.
Thursday, October 9, 2014
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 conflict 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.