93% of South African Maternity Wards Unsafe for Mothers and Babies

Despite the constant claim from UNAIDS and the HIV industry that HIV is almost always transmitted through unsafe heterosexual sex in African countries, though nowhere else in the world, it has yet to be demonstrated how appalling conditions in hospitals in high HIV prevalence countries hardly ever result in HIV and other serious diseases being transmitted. After all, relatively unsafe conditions in Western countries have resulted in incidents of healthcare transmitted HIV on numerous occasions. TB has been transmitted in hospitals in South Africa. So why not HIV and other bloodborne diseases?

A recent audit carried out in South African hospitals found that 93% of maternity wards are not safe for mothers or babies. This is no surprise to people who have frequently commented on the fact that HIV prevalence is often higher among women who give birth in health facilities than it is among women who give birth at home. But South Africa has the highest HIV positive population in the world. Do UNAIDS and the HIV industry really want to stick to their contention that these conditions hardly ever result in HIV transmission?

In the past, UNAIDS’ response has been that they would prefer to see people attending health facilities, as it is better for their health. But there is a lot of evidence that health facilities are not safe places. Even the UN itself has issued guidance to their own employees to carry their own medical equipment when working in high HIV prevalence countries, as safety in health facilities can not be guaranteed unless they are ‘UN approved‘. So they can’t have it both ways: if health facilities are unsafe for UN employees, they are unsafe for South Africans.

In the absence of any other explanation, I would suggest that UNAIDS and the HIV industry exhibit a profound form of institutional racism and sexism (because far more women are infected with HIV than men). I could be wrong and the industry may have the best interests of South Africans at heart. But if that’s the case, why is almost all the industry’s literature about sexual behavior and a few other things considered to be illicit or even illegal, such as intravenous drug use, male to male sex and commercial sex work?

HIV transmission through contaminated blood is extremely efficient, which is why intravenous drug use is so dangerous. But the highest use of syringes and other skin piercing instruments is found in health facilities (and also in traditional medicine practices, pharmacies, hairdressers, tattoo parlors and various other contexts to which UNAIDS and the industry appears to be completely blind). Hundreds of millions of injections are given every year; the majority are either unnecessary or the treatment could be administered non-invasively.

Apparently the maternal mortality rate is a massive 310 deaths per 100,000 live births in South Africa. In addition to threatening the lives and health of mothers, these conditions threaten the lives and health of babies and young children too. People are not made aware of the dangers of hospital transmitted infections. And what hospital transmitted infection could be more of a risk in extremely high prevalence areas than HIV? The virus tends to be far more common in built up areas, close to main roads and hospitals. In contrast, it tends to be a lot less common in more rural and isolated areas.

Yes, people need accessible healthcare, but no, not at all costs. If healthcare is unsafe, as it clearly is in South Africa and many other African countries (where conditions can be so bad that most people don’t use health facilities, and HIV prevalence is a lot lower), this will not reduce the transmission of HIV or other diseases. The worst place to go if you want to avoid a transmissible disease is a hospital if conditions there are as bad as they are in most African countries. Indeed, some epidemics, such as ebola, have hospitals as their epicenter, and the epidemic is only stopped when the hospital is closed.

This is not to say that all health facilities are dangerous, though the majority of them seem to be in South Africa. Nor is it to say that all healthcare workers could be doing more harm than good, though a lot seem to be doing harm in South Africa. Congratulations to the country on publishing the report, but it won’t do anyone any good until people are aware of the risks they face, and especially of the fact that HIV is not always transmitted sexually. Some of the worst HIV epidemics were almost definitely started by unsafe healthcare practices. How do we know that these same practices are not still contributing to some of the worst epidemics?

Out of 3,880 hospitals audited, some other findings include:

• Only 32 of the facilities audited complied with infection prevention and control;
• Only two facilities could guarantee patients’ safety;
• Just 161 facilities were clean enough to meet the audit’s tough standards; and
• Staff attitudes towards patients were awful – just 25% of staff in clinics were found to embody positive and caring attitudes

It’s time to stop treating South Africans and other Africans as if they are somehow different from non-Africans, as if their sexual behavior is almost uniquely dangerous, as if everyone who is HIV positive must have engaged in some kind of illicit behavior. People need to know that hospitals are dangerous places so they can take steps to avoid being infected with HIV, TB, hepatitis or any other disease while in hospital. That means UNAIDS and the HIV industry need to give up their obsession with ‘African’ sexuality, sexual behavior and sexual mores. It’s not all about sex, so let’s act accordingly.

UNAIDS Getting to Zero: Zero Lies, Zero Double Standards and Zero Institutional Racism

According to George Ochoa “An infection spread by unsafe injection practices can happen anywhere” and finds that “Since 2001…at least 48 outbreaks caused by unsafe injection practices have occurred in the United States, with the majority (90%) in outpatient settings (10 in pain clinics and nine in oncology clinics). Twenty-one of the outbreaks involved hepatitis B or hepatitis C; 27 were bacterial. More than 150,000 patients required notification to recommend bloodborne pathogen testing following exposure to unsafe injections.”

But if UNAIDS is right, George Ochoa is wrong; HIV infections through unsafe injection hardly ever occur in high HIV prevalence countries, which are mostly in sub-Saharan Africa. That must explain why, since the HIV epidemic began 30 years ago, no outbreak investigations have been carried out in sub-Saharan Africa.

UNAIDS’ ‘Kenya Aids Epidemic Update 2011′ briefly mentions re-use of injecting equipment during immunization programs (which account for a small percentage of all injections administered). They say “In a study of young men (ages 18–24) in Kisumu, men who received a medical injection in the last six months were nearly three times more likely to be HIV-positive”.

However, the report also claims that a minuscule percentage of HIV infections were a result of any kind of unsafe healthcare and that “Sexual transmission accounts for an estimated 93% of new HIV infections in Kenya, with heterosexual intercourse representing 77% of incident infections. Adults in stable, seemingly low-risk heterosexual relationships make up the largest share of new HIV infections.”

Did they assess the non-sexual risks faced by those people in ‘seemingly low-risk’ relationships? The report says “Among adult participants in the 2003 Kenya Demographic and Health Survey who said they had “no risk” for HIV, nearly 1 in 20 (4.6%) were in reality HIV infected”. The implication is that all those people were infected sexually, but they just didn’t realize they were at risk. For the authors of the UNAIDS report, the people in question were either stupid, liars or stupid liars.

The report recognizes that if there is a large number of HIV positive people in the population, the risk for each sex act is higher. But they don’t acknowledge that the same circumstances also make the risk of infection from an unsafe injection or other skin piercing procedure far higher. HIV prevalence is about 10 times higher in Kenya than it is in the US. But there have been no reported outbreaks of HIV or any other disease as a result of unsafe healthcare in Kenya or any other sub-Saharan African country.

Another study, by WHO, says that “around half the injections used across the world are unsafe for administration, with a worse ratio in developing countries”. So is it possible that George Ochoa is right in stating that “An infection spread by unsafe injection practices can happen anywhere”, and UNAIDS wrong? Well, shocking as it may seem to those who look to UNAIDS as an institution that specializes in HIV, what they say to Africans is different from what they say to UN employees.

Here’s what they have to say to UN employees: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. 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. 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.“

They also say: “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.“

I don’t know about anyone else, but I tend to believe the warning they give to UN employees, but that suggests they are lying about the risk that Africans face from unsafe healthcare. Why would this august institution lie about a very serious risk of HIV infection in the highest HIV prevalence countries in the world? Well, I can’t answer that question. If it’s vital to warn UN employees, it should be vital to warn those who don’t actually have much choice about which health facilities to use, UN approved or otherwise.

UNAIDS’ current touchy-feely campaign is called ‘Getting to Zero: zero new infections, zero discrimination, zero Aids related deaths’. How about ‘zero lies, zero double standards and zero institutional racism’ as an alternative set of objectives?

WHO Acknowledges HIV Risk in Ugandan Hospitals?

I know infection control professionals are not common in African countries but I hadn’t realized that up till recently there were none at all in Uganda. I wonder how many there are in countries that have received only a fraction of the funding Uganda has received, especially HIV funding. A WHO article about their ‘African Partnerships for Patient Safety’ initiative announces that one hospital, seven hours drive from the capital city, now “has its own infection control professional, the first in the country”. The article proudly states that “just two years ago, patient safety was an obscure concept that was almost impossible for hospital staff to apply when faced with practical realities”.

Could this be the same WHO that tells us that the vast majority of HIV infections in Uganda are a result of unsafe sex? True, the fact that patient safety was an ‘obscure concept’ does not mean that HIV transmission through unsafe healthcare is common. Rather, it means that we, WHO included, have no idea whether such transmission is common or not. We don’t know what proportion of HIV transmission is a result of unsafe healthcare and, therefore, what proportion is a result of the WHO’s beloved sexual transmission. Not that this stops WHO, UNAIDS and others from droning on about African sexual practices, ‘dry sex’, concurrency, circumcision, widow inheritance, long distance truckers, commercial sex workers and the rest, as if that’s all there is to HIV epidemics where many of the people infected face little or no obvious sexual risk.

The most striking thing about the official Modes of Transmission Survey for Uganda is that the largest group contributing to new infections consists of people in stable heterosexual couples. In many of those couples the index partner, the one infected first, is female (fewer males are infected but there is equally little evidence that they were all infected through unsafe sex). As the first to be infected, these women could not have been infected by their partners. So how were they infected? According to UNAIDS and WHO thinking, they must have had sex with someone other than their partner. The UN’s IRIN news service refers to them as ‘cheaters’, which is a reflection of IRIN’s typical style and level of sensitivity. But can the Modes of Transmission Survey rule out non-sexual transmission of HIV through unsafe healthcare, traditional and cosmetic practices in this group of people who face such low sexual risk? The simple answer is ‘no’. For UNAIDS, WHO and other institutions, it is simply taken for granted that the bulk of transmission is through unsafe sex. Questions about non-sexual risks are rarely raised and peremptorily dismissed if mentioned.

Survey after survey shows that those who engage in unsafe sex are no more likely to be infected that those who don’t; often, those who don’t engage in unsafe sex are more likely to be infected. High HIV prevalence does not tend to cluster in isolated areas, except where there have been major health programs. It does tend to cluster among wealthier, better educated, more mobile, employed people who are close to major transport routes and close to or in major cities; coincidentally, they also tend to be much closer to health facilities. Is one infection control expert in an isolated hospital in Uganda going to make much difference to transmission rates? Possibly in that hospital. But it is the initial assumption made by WHO, UNAIDS, etc, that needs to change: knowing someone’s HIV status tells you nothing about their sexual behavior and knowing about their sexual behavior is not a good predictor of their HIV status.

That may sound counter-intuitive if your ‘intuition’ is based on reading mainstream press, and even much of the more specialized scientific literature. HIV in African countries is almost invariably associated with sexual behavior. In Western countries this is not the case. HIV in wealthier countries tends to be attributed to intravenous drug use and male to male sex. Even in Asian countries, people are sometimes given a little benefit of doubt; they may have been infected through unsafe healthcare. But in African countries with the worst epidemics, there has never been an investigation into healthcare practices; there has never been an investigation into why so many women in Uganda (for example) are infected when their husbands are not, and where these women did not face any other obvious risks; there has never been an investigation into why so many babies are infected when their mothers are not; in fact, what proportion of babies are infected whose mothers are not? We don’t know the answer to these questions we appear not to even want to ask.

Does the ‘African Partnerships for Patient Safety‘ indicate an admission that patient safety could be a factor in some of the world’s worst HIV epidemics, after thirty years of insisting that HIV is all about sex and wasting billions of dollars accordingly, or is it mere lip service? I won’t be holding my breath.

Maternal Health Care a Significant HIV Risk in Ethiopia

[Cross-posted from the HIV in Kenya blog.]

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I’d like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It’s not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various ‘initiatives’ aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting ‘cheaters’. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be ‘cheaters’ could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It’s certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don’t know they are infected. It must also be remembered that most people don’t realize that there are significant non-sexual risks; if they don’t know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people’s worries in countries like Ethiopia, but only because many people don’t attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Circumcision: a Case of Retributive Healthcare?

[Cross-posted from the HIV in Kenya site.]

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because “there is no guarantee of the proper sterilization of such materials.” UN employees are also reassured that “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.”

The US Centers for Disease Control (CDC) states that “Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States.“

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

• 230,000 HIV Infections
• 1,000,000 Hepatitis C Infections
• 21,000,000 Hepatitis B Infections
• The above resulting in 1,300,000 deaths each year (WHO figures)
• Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
• At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force ‘healthcare’ in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of ‘retributive healthcare’.

The African Circumcision Experiment: Donor Driven?

[go to or return to first circumcision page]

I have spent the last two weeks in the West of Kenya trying to get people’s views on mass male circumcision, what is called the ‘Voluntary Medical Male Circumcision’ (VMMC) program. I have written notes about my visit on my blog, HIV in Kenya, but I should summarize the main findings here as they are not difficult to summarize, and as male circumcision is a very important potential HIV risk in Kenya. I admit, it has been very hard to find ordinary people who will talk about the subject, though I have found some. But it hasn’t been so hard to get people deeply involved in the VMMC program to argue the case for circumcising millions of Africans. As I shall explain, the case is even weaker than I thought before coming here.

The main finding is that VMMC is driven by money, by donor funding. There are copious amounts of donor funding available for male circumcision, but there are is very little funding for healthcare, unsafe or otherwise, education, infrastructure, employment or any other area of development. Everyone involved in HIV, health, development, etc, needs to apply for donor funding and they know they are wasting their time if they apply for funding for things donors don’t currently place any emphasis on. Everyone knows that HIV projects get funding, but only certain kinds: these must presuppose that almost all HIV transmission is through heterosexual sex. Circumcision ticks all the boxes.

Another finding is that even the proponents of VMMC are not convinced by the evidence for the community level effectiveness of such a program. They accept that the evidence of partial protection gleaned from randomized controlled trials (RCT) suggests that the level of protection that can be expected at a community level may be very low; it may even be cancelled out by other factors that result in increased HIV transmission as a result of VMMC. However, they appear to agree that interventions that have been carried out so far, such as various types of (sexual) behavior change communication (BCC), has not worked very well. Some say BCC hasn’t worked at all.

Curiously, despite the agreed lack of effectiveness of BCC programs, those defending VMMC say that they are not proposing mass circumcision on its own; no, they are proposing VMMC plus BCC. When it is pointed out to them that a program that doesn’t work combined with a program that is unlikely to be very effective still equals yet more ineffective intervention, they tend to revert to the ‘what else can we do’ attitude, along with the argument that it is the donor who decides what gets funded. The most defeatist people I could find were the proponents of VMMC themselves. Most of them didn’t even seem convinced of its potential effectiveness at a community level, all they know is that they will get paid.

It’s been hard to find people who are less closely connected to VMMC to talk, particularly to be interviewed in front of a camera, which is something I have been trying to do. Some of them say they don’t beleive the program will have much effect. But some say they believe it will work. People tend to know that the operation does not claim to give 100% protection but they don’t realize that the 60% protection claimed from the RCTs does not equate with 60% protection at the community level. While 60% (or more, or less) protection is a difficult enough concept to explain, explaining the difference between RCTs and community level interventions is not so difficult; everyone knows that if you pamper people for a while you will get quite different results from when you round them up and squeeze them through some kind of industrial process (ie, VMMC).

We have been bombarded with claims about circumcision giving partial protection against HIV; what has not been so clear is that the evidence for partial protection is itself only partial (pun intended). We don’t know what 60% protection in an RCT would amount to at the community level. Worse still, we need to wait another 6 years to find out, because the 10 year program in Kenya is only in its fourth year. This is not so much a community level intervention as a community level experiment. The only people I’ve found who seem to be aware of this is the proponents of VMMC. Is it unfair of me to compare this to the Guatemala syphilis experiment, referred to by Barak Obama as a crime against humanity? Or is it more like the Tuskegee syphilis experiment, referred to by Bill Clinton as racist?

The victims of this kind of human experimentation without informed consent (people do not consent to being part of an experiment and they are not given adequate information about the risks of circumcision nor the level of protection against HIV they can expect, although that is not even known) are not just the Luo men and possibly infants who will be circumcised under the VMMC program. The sexual partners of those circumcised are also deceived about levels of protection and risk. And even Kenyans who already circumcise, for traditional or other reasons, are deceived about protection and risk involved where HIV and circumcision are concerned, although it does not target them, specifically. So why circumcision? Because the money says so.

For more on circumcision, see also Don’t Get Stuck’s male circumcision section.

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.