Denied, withheld, and uncollected evidence and unethical research cloud what really happened during three key trials of circumcision to protect men

Advocates for circumcising millions of men to curb Africa’s HIV epidemics claim the program is based on sound evidence from well-done scientific studies. Advocates cite three key studies – in South Africa, Kenya, and Uganda — to say that circumcising men reduced the rate at which they got HIV by more than 50% by reducing their risk to get HIV from sexual partners.

But that’s not what the studies found. To expose the confusion about what these studies show, let’s start with what they did and what they reported.

South Africa study: The first study to report was carried out in South Africa during 2002-05. The study team solicited men willing to be circumcised, then on a random basis assigned half the men to an intervention group to be circumcised first and the other half to a control group to remain intact (uncircumcised) until the end of the study. The study team then followed and retested the men – circumcised and intact – at scheduled visits over as long as 2 years.

During follow-up, 20 men in the intervention (circumcision) group got HIV at the rate of 0.85% per year, while 49 men in the control (intact) group got HIV at the rate of 2.11% per year. If all the men’s infections came from sex, this is good evidence that circumcision cuts men’s risk to get HIV from sexual partners from 2.11% to 0.85% per year.

But did all or even most infections come from sex? Not according to evidence the study collected and reported. Twenty-three of the 69 men with new infections said they had no sexual partner or always used condoms from their last HIV-negative test to their first HIV-positive test. Men reporting no sexual risks got HIV at the rate of 1.11% per year. If these men are telling the truth, they apparently got HIV from blood during injections, dental care, tattooing, and other skin-piercing events. If men with no sexual risks got HIV from blood, it’s likely all men – even men with sexual risks – got HIV from blood contact. The rate of getting new HIV infections in men who reported at least one unprotected (without a condom) sex event was 1.86% per year, only 0.75% faster than for men reporting no sexual risks. The modestly faster rate to get HIV in men with vs without sexual risks explains less than 1/3 of the men’s infections (using standard epidemiologic analyses and terms, the crude population attributable fraction of incident HIV associated with having any vs no unprotected sex is 27%).

The study team could have done a better job identifying the sources of men’s infections if they had asked more questions and reported more data. But where is the failure? Did they not ask, or are they not telling? Like most studies on HIV risk in Africa, this study has not provided public access to collected raw data (with safeguards to protect participants’ confidentiality). Also, like most studies on HIV risk in Africa, this study has not disclosed its questionnaire and data collection forms – so there is no public record of what information they collected and chose not to report (chose to withhold).

From the published record, it’s likely that some crucial evidence about sexual risks was simply not collected – for example, there is no indication the study team traced and tested any of the men’s sexual partners. There were not a lot of partners to trace: 4 men with spouses got HIV, and 55 men who reported 0-1 non-spousal partners got HIV.

As for estimating how many infections came from blood exposures, the study team could have done this by asking men what skin-piercing procedures they had and then looking to see if men reporting various procedures were more likely to get HIV vs men without those procedures. The study reported two measures of health care exposure in men with and without HIV infection. According to one measure, men who “attended a clinic for a health problem related to the genitals” were 6.8 times more likely to get HIV than men without this risk. According to the other measure, men who reported injections and/or transfusion and/or hospitalization were 1.7 times more likely to get HIV than men who reported none of those events (see Authors’ reply in this link).

Notably, both reported measures of possible exposure to HIV through skin-piercing procedures had a bigger impact on a man’s risk to get HIV than did possible exposure to HIV during sex (having any vs no unprotected sex). The study’s reported measures of blood-borne risks are vague: The study team has not said what procedures men got at clinics treating genital health problems. The team has also not reported HIV incidence separately for injections, for transfusions, and for hospitalizations. The study has not reported other skin-piercing health care procedures, such as infusions or dental care, and we don’t even know if they collected such information. The study has also not reported any data on skin-piercing cosmetic procedures; did they ask?

 Table 1: What information on sex and blood risks did the three studies collect and report for men with and without new HIV infections?

Risks for HIV		South Africa, 2002-05	Kenya, 2002-06	Uganda, 2003-06
Blood-borne risks
	Injections	Collected but not reported	Unknown	Unknown
	Transfusion	Collected but not reported	Unknown	Unknown
	Hospitalization	Collected but not reported	Unknown	Unknown
	Injections, transfusions and/or hospitalization	RR=1.7	Unknown	Unknown
	Visiting a clinic for a genital health problem	RR=6.8	Unknown	Unknown
	Infusions	Unknown	Unknown	Unknown
	Dental care	Unknown	Unknown	Unknown
	Scarification	Unknown	Unknown	Unknown
	Other blood risks	Unknown	Unknown	Unknown
Sexual risks
	Any vs. no partners	Collected but not reported	Collected but not reported	RR=2.4
	<100% condom use	Collected but not reported	Collected but not reported	RR=1.1
	Any vs no partners or <100% condom use	RR=1.7	Collected but not reported	RR=1.6
	Any vs no non-spouse partner	Collected but not reported	Collected but not reported	Collected but not reported
	HIV status of spouse	Not collected	Not collected	Collected but not reported
	HIV status of non-spouse partners	Not collected	Not collected	Not collected

Sources: see references in the text. RR: crude hazard ratio (calculated as the rate of getting HIV with the risk divided by the rate without the risk).  

Kenya study: The Kenya study, 2002-06, was similar in design to the South Africa study. The study circumcised some men, then followed and retested circumcised and intact men for as long as two years to see who got HIV. Nineteen men in the intervention (circumcised) group got HIV at the rate of 1.9% over two years, while 46 men in the control (intact) group got HIV at the rate of 4.1% over two years.

How many of the 65 men got HIV from sex? The study reports information on sexual behavior vs HIV for only 7 men infected during the first three months of follow-up. Five of these seven men reported no sexual partners from the time they entered the trial (using sensitive tests, the study could not find HIV in blood collected then) until their first HIV-positive test after 1-3 months. Four of the men with early infections had been circumcised in the study clinic. All four were found with HIV one month after their circumcision; three reported no sexual partners in that month. Contaminated local anesthetic or contaminated instruments could have infected the men during circumcision – the study team could have investigated the possibility, but there is no indication they did so.

What about the other 58 infections? The study asked men about sexual partners and condom use throughout the trial, but does not report this information for men with and without new HIV infections. The study team has said nothing about tracing and testing men’s sexual partners – did they do it and not report it, or just not do it?

As for blood-borne risks, the study says nothing – no report of what data were collected, and no disclosure of any collected data. This is a glaring oversight, because the study team had in hand evidence linking HIV in the community to blood risks. Among men tested as part of the process to recruit men for the trial, those who reported skin-piercing procedures were more likely to be HIV-positive (and thus not eligible for the trial). Specifically, men who reported one or more injections in the previous six months were 2.0 time more likely to be HIV-positive vs other men; men who had ever been tattooed were 2.2 times more likely to be infected; men who had ever received saro (traditional blood-letting) were 2.0 times more likely to be infected; and men who reported “blood exchange” were 18.6 times more likely to be HIV-positive.

Uganda study: The study in Uganda, 2003-06, followed the same design as studies in South Africa and Kenya: assigning men randomly to be circumcised or to remain intact, then following them for as long as long as two years to see who got HIV. Twenty-two men in the intervention (circumcised) group got HIV at the rate of 0.66% per year, and 45 men in the control (intact) group got HIV at the rate of 1.33% per year.

But how did the men get HIV? Six men with new HIV infections reported having no sex partners during the period between their last negative and first HIV-positive test. Ten others with new infections reported always using condoms. Taken together, the 16 men who reported no possible sexual exposure to HIV got HIV at the rate of 0.72% per year – presumably from skin-piercing events that exposed them to HIV in blood. Men who reported any unprotected sex acquired HIV at the rate of 1.17% per year, only 0.45% per year faster than men reporting no sexual risks. As in South Africa, the marginally faster rate at which men who reported sexual risks got HIV explains less than a third of the infections observed during the trial (using standard epidemiologic analyses and terms, the crude population attributable fraction of incident HIV associated with having any vs no unprotected sex is 29%).

Unlike the other two studies, the Uganda study team traced and tested most of the men’s wives (and other long-term partners) for HIV; this was done as part of a parallel study of the impact of circumcision on men’s and women’s risks for other diseases. However, the study did not report the wives’ HIV status for men who did and did not acquire HIV infection; this is important information, because married men accounted for about half of the infections. Did they get HIV from HIV-positive wives? The study team is sitting on that information. The study team has also not reported how many men with HIV-negative wives got HIV despite no reported non-spousal partners.

Based on the study team’s partial disclosure of collected information on sexual risks, most infections came from skin-piercing events. To determine the sources of the men’s infection, it is relevant to know about skin-piercing events in men who did and did not get HIV. However, as in the Kenya study, the Uganda study team provides no report of what data was collected on skin-piercing procedures, and discloses no collected data on skin-piercing procedures.

Ethical short-comings: The three studies treated research participants in ways that would not be allowed in the US and France, the countries that funded the studies.

The South Africa study recruited men and the Uganda study recruited wives without insisting they hear their HIV test results. Neither study has said how many people the study followed who did not hear their results. This would not be allowed in the US, where a condition of recruitment in studies that follow people to see who gets HIV is that participants must be willing to hear their test results.

The design of the Uganda study allowed the study team to follow wives who did not know they were HIV-positive to watch them infect men who did not know they were at risk. The study allowed this to happen because it tested and recruited wives without insisting they hear their test results, and without insisting they share those results with their husbands. This would also not be allowed in the US – where regulations ask that doctors and counselors warn spouses if the HIV-positive partner will not do so. The study has not said how many unsuspecting men got HIV from wives the study knew were infected.

None of the studies insisted that men who acquired HIV bring their wives for couple counseling. This ethical lapse – leaving wives with unknown risks – undermined the objective of the research, which was to see how much circumcision reduced sexual transmission. Bringing in and testing wives after men got HIV would not only protect HIV-negative wives, but would also provide information about how many infections came through sex, and how much circumcision reduced HIV from sex.

Table 2: Ethical short-comings in the three trials

Ethical issue	South Africa, 2002-05	Kenya, 2002-06	Uganda, 2003-06
Did the study enroll people who refused to hear their HIV status?	No	Yes	Yes
Did the study follow men not aware their wives had tested HIV-positive?	No	No	Yes
Did the study insist that men who got HIV during the trial bring their wives for couple counseling?	No	No	No

Mass circumcision based on assumption, not evidence: Campaigns for mass circumcision in Africa began in 2007, shortly after three studies – in Kenya, South Africa, and Uganda – concluded that circumcision cut men’s risk to get HIV by 51% to 60% by reducing men’s risk to get HIV from sexual partners.

Those conclusions are based on assumption, not evidence. According to what men reported about sexual behavior in two trials, only a minority of their infections came from sex. It is, of course, possible that men lied about their sexual behavior. But with that argument, realize what has happened: The $1.5 billion enterprise to circumcise 20 million men in Africa is no longer based on evidence. It’s based on assuming away evidence. It’s based on a prior belief – inconsistent with evidence from these trials – that almost all HIV infections in African adults come from sex.

How did the men get HIV, and how did circumcision affect sex and non-sex risks? We don’t know what happened in these studies. This is due at least in part to failure on the part of the study teams to report all collected data. None of the study teams has even said what data they collected. But the scientific errors started earlier. None of the studies collected all relevant information required to measure and to explain the impact of circumcision on men’s risk to get HIV – asking comprehensively about blood and sexual risks, and tracing and testing all long-term and short-term sexual partners.

Long past time to listen, believe, and investigate

There would be no HIV epidemic if doctors and nurses in Central and West Africa had not reused syringes and needles during 1900-1960. We’d worry about other things. And health aid programs would be begging for money for other things. But no one would have heard of HIV.

The charge – accusation – that colonial health care programs started the HIV/AIDS epidemics does not come from a wacko conspiracy theorist. Jacques Pepin, an accepted mainstream scientist, elaborates the charge in his new book, The Origins of AIDS. Peter Piot, the chairman of the AIDS establishment – the long-term former head of UNAIDS – seconds the charge: “As far as the origins of AIDS are concerned…it will be difficult to come up with a better explanation than Pepin’s. The role of medical injections in the initial spread of HIV in Africa is quite plausible.”

Pepin’s story of AIDS origins begins with hunters and butchers who sometimes get blood from chimpanzees into cuts. On rare occasions, chimpanzee blood infects a hunter or butcher with simian immunodeficiency virus (SIV), at which point we call it HIV (human immunodeficiency virus). But it’s what happens next that’s important. Pepin argues – with a lot of evidence – that sexual transmission of HIV from a cut hunter or butcher to spouses and others was too inefficient – too slow – to sustain a chain of infection among humans. Without unsafe injections to spread HIV, the cut hunter or butcher would have died without spreading the infection. And there would be no epidemic.

But after making sense of the beginning of the epidemic, Pepin, Piot, and the rest of the AIDS establishment tell another and conflicting story. They want us to believe that although sexual transmission was too inefficient to start the epidemic, it later became so efficient that it accounts for almost all HIV infections in African adults. That makes about as much sense as saying pigs can’t take off and fly, but if you throw them into the air, then they can fly.

Mainstream AIDS experts have been persistent for almost 30 years in their claim that almost all HIV in African adults comes from sex. Let’s be clear what this claim means and where it comes from.

The claim is an accusation. Most couples with HIV in Africa are discordant – one is HIV-positive, and the other is HIV-negative. The claim that almost all HIV comes from sex accuses millions of men and women in discordant couples of having sex outside marriage. In discordant couples, women are the HIV-positive partner as often as men. Because women are generally the first partner tested (during antenatal care), the accusation that almost all HIV comes from sex targets especially women. The consequences can be harsh: A recent news story tells of a woman in Kenya who tested HIV-positive during antenatal care, and then brought her husband to test. When he tested HIV-negative, he accused her of being pregnant by another man and threw her out of the house.

Where does the claim (accusation) come from? It doesn’t come from evidence. After 30 years of research, the AIDS mainstream is still unable to point to anything different about sex in Africa that could explain how HIV infects so many people. Studies repeatedly show that sexual behavior in Africa is similar to, if not more conservative than, sexual behavior in Europe or the US. It doesn’t come from models: Models shows that sexual behavior in Africa combined with known rates of sexual transmission could not create Africa’s HIV epidemics.

On the other hand, study after study in Africa finds HIV-positive men and women who report no possible sexual exposures to HIV – such as virgins, and people with an HIV-negative spouse and no other lifetime sex partner. What do AIDS experts do with this evidence? Studies characteristically conclude that those who report no sexual risks got HIV from sex – and then lied about it. No matter what studies find and Africans say, the accusation remains: If you are African, you got HIV from sex.

The accusation that almost all HIV infections in African adults comes from sex not only blames HIV-positive adults for unwise sexual behavior but accuses and stigmatizes Africans in general for unusual sexual behavior and lack of human feelings. It’s a riff on historic characterizations of Africans as sub-human, close to animals, and backward.

Euphemistically, we could call the accusation an hypothesis, or in layman’s terms, a guess. But considering the lack of supporting evidence as well as persistent contradictory evidence, it hardly qualifies as a legitimate hypothesis waiting for tests and proof. It’s a dangerous wolf that masquerades in sheep’s clothing as a respectable hypothesis.

Which brings us to the question: Who gains? Health aid managers, health care providers, and ministries of health across Africa gain by blaming HIV-positive Africans for unwise sexual behavior. The alternative is to accept some of the blame for Africa’s ongoing epidemics. Does unsafe health care spread HIV in Africa today as in colonial times? A lot of evidence says so. To see if it’s so, and to find and stop dangerous health care procedures, ministries of health need to investigate unexpected infections. When a woman is HIV-positive with no sexual risks, it’s unlikely she is the only woman who’s been infected by the responsible clinic. How many were infected – tens, hundreds? Without looking – testing other women who visited the same clinic – we won’t know, and we won’t find the risk and stop the ongoing clinic-based HIV outbreak.

Health care professionals have a common conflict of interest that discourages them from talking about ongoing HIV transmission through health care. This common conflict of interest creates what could be called a natural conspiracy of silence about bloodborne risks for HIV. If any health care professional wants to challenge that assessment, here’s how – Call publicly for investigations of unexpected HIV infections. Show that you, at least, are not part of a conspiracy of silence about HIV transmission through health care in Africa.

Is misogyny misleading the response to Africa’s HIV/AIDS epidemics?

Everyone has prejudices. Trying to overcome them can be like playing the arcade game whack-a-mole. See it, whack it. It pops up again, whack it again. The AIDS epidemic energizes a lot of prejudices. Unfortunately, the international AIDS industry – organizations and individuals getting money to do something about AIDS, including aid agencies, researchers, and others – has not been alert to see and reject common prejudices.

For example, even though careful surveys show that heterosexual behavior in Africa is similar to behavior in the US and Europe, most AIDS experts say that sexual behavior explains Africa’s terrible epidemics. Because the AIDS industry has not yet whacked racial stereotypes of sexual behavior, it has not yet been compelled to look for something other than sex that is different in Africa, and that could help to explain how HIV can infect 5%-26% of adults (50-260 out of 1,000 adults) in 15 countries in Africa compared to only 0.3% of adults (3 in 1,000) outside Africa.

But it’s not only racism that misdirects the AIDS industry’s response to Africa’s epidemics. Another prejudice – misogyny – seems to do so as well. Features of two prominent health aid programs in Africa – circumcising men, and extending birth control to women – suggest that misogyny is a hidden influence.

Circumcision: During 2005-07, studies in Africa reported that circumcising HIV-negative men reduced their risk to get HIV by 53% (median result from three studies), but that circumcising HIV-positive men increased transmission to their wives by 49% (result from one study). Based on these studies, donors initiated crash programs to circumcise millions of African men. Critics point out that circumcised men will still have to use condoms to be safe (not just safer). But since we’re focusing on women, let’s leave aside arguments that mass circumcision is not a good way to protect men.

Let’s focus instead on what was done with the evidence that circumcising HIV-positive men increased their partners’ risk to get HIV by 49%. Notably, in the study that reported that statistic, wives of circumcised men were at especially high risk if they resumed sex before their husbands’ circumcision wound healed – 5 (28%) of 18 who did so got HIV in the 6 months after their husbands were circumcised.

Programs offering subsidized circumcisions could protect wives by requiring that men asking to be circumcised be tested for HIV, and if found to be infected bring their wives for couple counseling before proceeding with the circumcision. Instead, the Joint United Nations Programme on AIDS (UNAIDS) recommends: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative.”[1] As mass circumcision programs got underway, as many as 1/3^rd of men resumed sex before wound healing. Lack of care to protect women suggests misogyny – or is it just careless incompetence that happens to hurt women?

Hormone injections for birth control: During the last several decades, many studies in Africa and Asia found that women taking hormone (progesterone) injections for birth control were more likely to get HIV compared to women using other birth control methods. A similar risk is found with monkeys: As early as 1996, scientists studying SIV (simian HIV) in monkeys found that progesterone implants multiplied by 8 times their risk to get SIV. Progesterone thinned the monkey’s vaginal wall and enhanced virus replication. Another HIV risk with hormone injections is that careless providers might reuse unsterilized syringes and needles, transmitting HIV from one woman to another.

Despite the evidence, WHO continues to say hormone injections are safe for all women, and donors continue to push hormone injections for birth control – especially in Africa. Outside Africa, 3% of women (partnered women aged 15-49 years) use hormone injections. In contrast, in Kenya, Lesotho, Malawi, Namibia, South Africa, and Swaziland, the percentage of women using hormone injections increased from 6%-20% in 1996 to 17%-29% in 2009. In these same countries, 6%-26% of adults are HIV-positive.

Compare what the AIDS industry does to protect men vs. women: In 2011,  a study among discordant couples (in which only one partner is HIV-positive) in Africa reported that women taking hormone injections for birth control were more than twice as likely to acquire HIV from their husbands compared to women using non-hormone methods. From this data, helping women shift from hormone injections to safer methods would cut their risk for HIV by 54% — as much as circumcision seemed to protect men in several recent studies. How did donors respond? Donors budget hundreds of millions of dollars to circumcise African men, but no donor has committed even one dollar to shift women from hormone injections to safer birth control methods. As of late 2011, the aid-for-family-planning industry, including notably USAID, continues to push hormone injections in Africa.

Donors’ lack of urgency to help women shift from hormone injections to safer birth control methods suggests not only misogyny but also confusion. According to a recent study among discordant couples (mentioned in the previous paragraph), shifting HIV-positive women from hormone injections to non-hormone methods of  birth control could cut HIV transmission to men by 67% — cutting men’s risk even more than what has been estimated with circumcision. Is the AIDS industry so confused by the first person protected (men who get circumcised; women who stop taking hormone injections) that it is unable to see the overall impact?

Other signs of misogyny: Outside Africa, HIV infects mostly men. Where that’s the case, researchers have identified all important risks – most infections come from anal sex among men or from sharing syringes and needles to inject illegal drugs. Knowing their risks helps men to avoid infection and thereby limits the extent of HIV epidemics. Outside Africa, only 0.3% of adults are infected.

In Africa, HIV infects more women than men. In Swaziland, for example, HIV infects 31% of women vs. 20% of men. In the 28 years after AIDS was recognized in Africa in 1983, researchers have failed to do the simple research required to identify important risks for women – that is, to trace the source of their infections.

We know some women get HIV from their husbands. But we also know that in most African countries married women with HIV are more likely to have HIV-negative than HIV-positive husbands. We know that many self-reported virgin women are HIV-positive. We know that reuse of unsterilized medical instruments is common in Africa. So we know some things. But we don’t know enough. Failure to identify women’s risks may well be the key to failure to control Africa’s epidemics.

Other evidence of misogyny comes from the AIDS industry’s frequent  claims that prostitutes drive Africa’s epidemics. Throughout history, societies have blamed promiscuous women — especially prostitutes — for spreading sexually transmitted disease. Some studies in Africa have found a lot of prostitutes with HIV — but how did they get it? Notably, in most countries outside Africa, HIV is rare in prostitutes who do not inject illegal drugs. Few prostitutes in Africa inject illegal drugs, but they get other injections, such as antibiotics to treat sexually transmitted disease. Nevertheless, building on a long tradition of blaming prostitutes for society’s ills, the AIDS industry finds it easy to blame prostitutes’ HIV infections on sex, rather than to investigate to see how much unsafe health care not only infects prostitutes, but also spreads HIV from prostitutes to others. 

Finally, consider the different attention paid to sterilization of medical instruments in the Expanded Programme on Immunization (EPI), which began in 1974 and which treats mostly children, compared to what has been done in safe motherhood and family planning programs for women. During the 1980s and later, EPI’s donors arranged dozens of surveys of injection practices in immunization programs. These surveys found lots of unsafe injections. In 1999 a WHO committee acknowledged that 30% of vaccination injections were unsafe. To address the problem, EPI’s donors belatedly shifted vaccination injections to auto-disable syringes, which break after one use.  

Unlike EPI, programs promoting health care for women have not arranged surveys to see if health care is safe – e.g., how often are gloves, specula, and syringes reused without sterilization? Even so, there is a lot of evidence that women’s health care in many hospitals and clinics in Africa is not only unreliably sterile but has also infected women with HIV. For example, a 2005 national survey in Ethiopia found that 9.9% of women who gave birth in the last 3 years with delivery care from a health professional were HIV-positive vs. only 1.2% of women who gave birth but did not get such care. We don’t know where all those infections came from. Not knowing shows that no one has cared enough about women to do the simple studies to find the risks – tracing infections to their source – so that women can be warned and thereby protected. Donors’ head-in-the-sand approach to women’s exposures to unsterile instruments in health care mocks the “safe motherhood” slogan.

More than money is required to stop Africa’s AIDS epidemic – it also needs clear thinking.  That is hard to do when common prejudices are not recognized and whacked. If we see and whack racial stereotypes of African sexual behavior, we’re more open to evidence pointing to other explanations. If we’re alert to whack misogyny, we’re forced to take a good look at all the ways the AIDS industry harms and stigmatizes African women. Clear thinking can help to translate good intentions into protecting and healing actions.

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[1] Quote from p. 7 in: UNAIDS, 2008. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Available at: http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf (accessed 1 December 2011).

PrePex in Rwanda: Male Circumcision Associated with Higher HIV Transmission and Higher Profits

Rwanda, which has a shockingly low number of doctors and other health personnel per patient, is claiming that they can circumcise two million men in the next one and a half years. Even Kenya, which makes exalted claims, has only managed 250,000 or so in a longer period of time. Apparently, the trick is to be unchoosy about who carries out the operation. However, if large sums of money are available, why not train more personnel? The effect would be far more significant and sustainable and would benefit health in general, not just HIV alone.

Well, there are plenty of unemployed people in Rwanda, but this doesn’t sound like the best way to spend the 100 million dollars or so, which is about the lowest amount such a program could cost. And that’s just if everything goes well. If Rwanda can barely cope with the most minor, non-invasive medical procedures, why rush into circumcising most of the adult male population when there’s no guarantee it will be of benefit? In fact, it may even do a lot of harm.

Not many Rwandan men are circumcised, but in the latest figures available for HIV prevalence among circumcised men (2005, later figures are yet to be released), the operation would appear to increase transmission. This is nothing unusual; in many countries HIV prevalence is higher among circumcised men; prevalence for circumcised Rwandan men is 3.8%, compared to 2.1% for uncircumcised men. So what evidence is the country using to persuade men to undergo this operation when they will still have to use condoms, which could protect them from HIV, unplanned pregnancy and a whole host of sexually transmitted infections in one go?

Indeed, national HIV prevalence in Rwanda is relatively low, at 3%. But female prevalence is 3.6%, whereas male prevalence is only 2.3%. As in all medium and high prevalence countries, rates are far higher among women, especially urban dwelling women, wealthy women and women with the highest levels of education. And it is not even clear if transmission from men to women is reduced by male circumcision. There is evidence that transmission from men to women may increase as a result of a mass circumcision program.

It is often claimed that HIV prevalence among Muslim populations is lower and it is even stated or implied that this is because Muslim men tend to be circumcised. In Rwanda, HIV prevalence is indeed lower among Muslim men than any other religious group. But Muslims as a whole have by far the highest HIV prevalence because female rates stand at 11.4%, compared to less than 4% for every other religious group. (It could be argued that polygamy, said to be common among Muslims, results in higher HIV rates; but rates are often lower where polygamy is common; besides, many non-Muslim groups practice polygamy, even if they identify themselves as Christian.)

Apparently the PrePex device will be used to carry out the circumcisions, a simple piece of plastic with an elastic band. This device has been widely advertised, especially through infomercials, and is backed by the Gates Foundation amongst others. One of the infomercials was run by the BBC; there’s a link to the clip in a blog post I wrote some months ago. But with HIV prevalence so low, 97% of the adult population are uninfected, how valuable could this operation really be (aside from the clear value to the manufacturers of PrePex and other commercial interests)?

If Contaminated Medical Waste Makes Dumps Dangerous, How About Hospitals

Medical waste is a serious threat in all developing countries, although it may not be as big a threat as reused contaminated equipment and other unsafe practices in health facilities. Thousands of people scrape a living from dumping sites by trawling for things that can be sold or reused. But if healthcare waste is not being dumped properly, they can come into contact with scalpels, needles, syringes, glass and other items.

The article above mentions the unlicenced clinics that are so common around all slums in Nairobi. But there is no mention of reuse of medical instruments. Perhaps it never happens, but even in legitimate health facilities, some healthcare workers seem to assume that safety precautions are to protect them from accidential exposure to pathogens, not their patients.

I’ve been to several health facilities in Kenya, Tanzania and Uganda and it is fairly obvious that some of the waste never makes it to dumps. It is not unusual to find used equipment on grassy areas, in bushes and in various places on the hospital grounds. I’ve even seen kids playing with clinical waste.

According to the article, backstreet clinics in Nairobi alone are being closed down at a rate of more than 15 a month. I’d be curious to get an idea of what kind of conditions are found in such clinics but I haven’t seen any reports. While those sifting through rubbish face some risk, patients may face even higher risk of illegal clinics are unaware of or not compliant with infection control procedures.

The article cites an estimate from the British Health Protection Agency that up to 1 in 300 people could be infected with HIV through contact with contaminated medical waste. But if that’s the case in the UK, where HIV prevalence is very low, the risk must be far higher in Nairobi, where prevalence is nearly the highest in the country. The risk of hepatitis and other blood borne diseases is even higher still.

If reports of conditions in Kenyan hospitals are true, unhygienic conditions in dump sites must be the least of their worries when it comes to accidental infection with HIV and other blood borne diseases.

HIV Risk from Blood Transfusions and Tattoos

Further to a recent report that parents of 23 thalassemic children who were thought to have been infected with HIV through contaminated blood transfusions were calling for an investigation, it appears their demands are being met, at least in part.

There will be an investigation to, in effect, establish who to blame for the outbreak. The families have a right to expect compensation, but how about recognition that healthcare associated transmission of HIV (and other diseases) can and does occur? How about an investigation to establish how often such incidents occur elsewhere, or how often they might occur in the future? Don’t we want to prevent HIV?

Once the issue becomes top-heavy with lawyers, they are the only ones who will benefit to any great extent. But it is possible that many people are vulnerable to infection with HIV, hepatitis and other diseases through unsafe healthcare, and indeed, unsafe cosmetic procedures. It’s not just children who are at risk, everyone who receives any kind of skin-piercing treatment, whether medical or otherwise, is at risk.

A reminder that unsafe healthcare is not the only possible source of HIV and other diseases comes from an Australian, who is suspected of having been infected after getting a tattoo in Bali. It’s not surprising that it takes one Westerner to become infected for an entire mode of transmission to be investigated, but this is the kind of warning that should have been heard in the run up to the World Cup in South Africa. Instead, there was little published but the usual fatuous rubbish about sex.

HIV experts are well aware that conditions in non-Western countries can be dangerous and that HIV can be transmitted in healthcare and cosmetic facilities: “While tattooists in Western Australian must comply with strict regulations and a code of practice, tattoo parlours overseas may not meet the same standards.” It’s just rare to read about exactly what this means for Westerners. But if Westerners are at risk, so are non-Westerners.

That may come as a surprise to UNAIDS, who are fond of warning their own employees and, at the same time, denying that non-sexual HIV transmission plays a significant role in African epidemics. Worse still, they don’t feel any attention should be given to non-sexual transmission, with the result that people are pretty confused about sexual transmission and totally in the dark about non-sexual transmission.

If I haven’t made it clear before, I think UNAIDS is an expensive waste of money that could be spent on health and development in general, rather than supporting the sexual fantasies of a bunch of overpaid and ineffective bureaucrats.

Conflating Product Safety With Safety of Health Procedures is Dangerous

A woman in the Indian state of Andhra Pradesh is thought to have been infected with HIV from a contaminated blood transfusion. The blood was purchased from the Red Cross blood bank. The woman had received several negative blood tests before the delivery so it is unlikely she was infected by her partner. The article doesn’t say whether her partner was tested.

While the risk of being infected through medical procedures may be low in India, where HIV prevalence is lower than it is in the US, the risk in Uganda and other African countries is a lot higher. Most Eastern and Southern African countries have HIV prevalence levels many times higher than those found in India.

Therefore, it’s surprising that health services in Uganda are being advised to continue using the injectible version of Depo Provera, despite evidence that it could be involved in higher transmission rates. Even if the hormone involved is not responsible for higher transmission rates, this does not rule out the possibility that unsafe injections are at least partly involved.

The article goes on about other worries, such as low contraceptive use, but this misses the issue of unsafe healthcare. In the long run, contraceptive use is not going to increase if the whole process of birth control becomes controversial. Rather than simply telling health services to continue using injectible Depo Provera, might it not be more reassuring to investigate safety conditions in health facilities?

The contraception agenda seems to be driven by outside interests, rather than by African countries. There may well be an ‘unmet need’ for contraception, but no one in their right mind would opt for a contraceptive method that carries risks of infection with HIV, or that increases the risk of transmitting HIV.

If those driving the contraception agenda wish to increase access to various birth control methods, they also need to be able to reassure people as to the safety of those methods. And that means the safety of the method of administration, not just the safety of the substance administered. The WHO may well wish to wait until their ‘high level meeting’ in January, but safety in health facilities should not have to wait.

In fact, we should not still be avoiding questions about HIV transmission in health facilities. Even if there were no evidence of healthcare associated infection or transmission, and that is far from the case, health facilities should be routinely inspected; they should always be able to account for their safety provisions. Right now, they are not able to do so.

If WHO and others don’t wish to address the safety or otherwise of Depo Provera, that’s bad enough. But the issue of patient safety in health facilities is far too urgent and far too long ignored to be treated in the same doctrinaire manner. HIV has been found to have been transmitted in many countries, rich and poor, in health facilities. The threat of nosocomial and iatrogenic transmission of HIV in African countries can not be dismissed any longer. As in the Indian case above, investigation is needed, not a continuation of summary dismissal of the evidence by international health institutions.

Outbreaks of Non-Sexually Transmitted HIV and Hepatitis C

Despite HIV prevalence standing at well below 1% in the sexually active population in India, 23 thalassemic children out of 100 tested have been found to be infected through contaminated blood transfusions in one year. Parents of infected children are demanding an investigation. Not only are the parents demanding compensation but there is also a possibility that health professionals involved will be investigated for criminal offences.

In China, a doctor is under investigation after 168 people were infected with hepatitis C. It is said they were infected by an unlicenced health practitioner who reused injection equipment.

UNAIDS Fesses Up a Little About Non-Sexual Risks

Guarding against transmission of HIV through blood transfusions has been found to ‘offer high returns’, which will be comforting for those who face especially high risk from such incidents. Blood transfusions are by no means the only route to HIV infection in health facilities, but the probability of transmission is very high; if someone receives a transfusion of HIV contaminated blood, they will almost certainly be infected.

However, while the probability of transmission is far lower for reused syringes, needles, intravenous drip equipment, etc, people are many times more likely to experience these procedures, often many times in their lives. In other words, these procedures may carry a low probability of transmission where the equipment is contaminated, but they happen so frequently that they could represent a significant risk to populations in countries where health facilities are in poor condition, as they are in many African countries.

The above article from the Financial Times mentions some countries, such as Angola, Niger and Tanzania, where “less than a third of donated blood is tested for HIV contamination in a quality-assured manner.” In fact, up to 90% of transfused blood given to pediatric patients may not receive adequate testing, according to research in Tanzania. The WHO even admits that “there is no reliable information on the extent of transfusion-linked infections”, which makes you wonder how commentators can claim that this risk is very small, especially in African countries such as Kenya, Uganda and Tanzania.

But the most interesting revelation is from Paul de Lay of UNAIDS, who says “if he were to have an accident near a rural hospital in some parts of Africa, he would seek a saline drip or other measures to defer the need for transfusion at least until arrival in a better resourced urban medical centre with greater chance of more effectively screened blood”.

There is some advice for Mr de Lay, which comes straight from his esteemed employer: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission.” They go on to say “We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN-approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere [my emphasis]. It is always a good idea to avoid direct exposure to another person’s blood—to avoid not only HIV but also hepatitis and other bloodborne infections.”

In other words, de Lay should refuse all medical attention where other people’s blood may be involved, if possible. But what about people who are not fortunate enough to work in the UN system? Are they not entitled to a warning, at least, concerning what UNAIDS calls the “most efficient means of HIV transmission”?

It’s hard to understand UNAIDS’ policy of exaggerating the relative contribution of sexual transmission and dismissing the relative contribution of non-sexual transmission, despite there clearly being a dearth of research into this area. Catherine Hankins, also of UNAIDS, seems to suggest that warning people about health care associated risks could result in them ignoring sexual risks and, at the same time, avoiding health facilities.

But is it true that people can not mentally process the two kinds of risk? Can we really not tell people in the countries with the worst HIV epidemics in the world that they face both sexual and non-sexual risks? That appears to be UNAIDS’ stance. Are we in the West not warned about intravenous drug use, tattoo parlors and health facilities in high HIV prevalence countries as risks for infection with HIV?

Maybe UNAIDS worry about ‘complacency’ regarding sexual risks is right; after all, the obsession with sex seems to have resulted in complacency regarding non-sexual risks, such as blood transfusions, other unsafe medical practices and even cosmetic and traditional practices that involve skin piercing. But that is no reason for claiming that 80-90% of HIV transmission in African countries is a result of heterosexual sex when we have little idea of what the relative contribution of non-sexual exposures is. People need to be warned about non-sexual HIV exposure; if it poses a risk to UN employees working in African countries, it poses a risk to all Africans.

Uganda Starting to Recognize Non-Sexual HIV Risks?

The Kenya HIV Modes of Transmission Survey lumps together its estimates of the respective contributions of men who have sex with men along with prison populations, as if the two groups are somehow inseparable. And there is often the implication that, where HIV prevalence is high in prison populations, it is as a result of sexual transmission, through men having sex with men, specifically.

So it’s unusual to find an article that discusses HIV rates among prisoners, such as this one from Uganda, where transmission is thought to result from sharing sharp objects, razor blades, needles and the like. Apparently, prisons can’t always afford to provide enough of these instruments, so they end up being shared between prisoners. This could be quite a risk, not just for HIV but also hepatitis and other blood-borne diseases.

HIV prevalence in Ugandan prisons is just over 11%, about twice the national level. Also, prison populations are predominantly male, whereas HIV prevalence is a lot lower among men in the general population.

Prisoners on antiretroviral drugs also say they are also poorly nourished and, as a result, fear taking their drugs, which have can have serious side-effects when taken on an empty stomach. However, this phenomenon is by no means confined to prison populations. Most HIV treatment programs place a high emphasis on supplying drugs but less emphasis on general health and nutrition.

Now that it is recognized that prisoners can face serious non-sexual HIV transmission risks, let’s hope the small step is made to recognizing the serious non-sexual risks that non-prisoners face in health facilities, cosmetic service outlets, traditional medicine practices, tattoo parlors, etc.