Don't Get Stuck With HIV

Protect yourself from HIV during healthcare and cosmetic services

Take a look at: Seeking the positives, by John Potterat

In an important contribution to the history of medical research, John Potterat’s new book, Seeking the Positives, recounts his involvement in research on sexually transmitted disease and HIV. Chapter 7 recounts researchers’ failure to explain how so many Africans get HIV (chapter 7 is available for download at

The AIDS epidemic has been a disaster for tens of millions of Africans. What has not been widely recognized is the damage to medical research – epidemiologists have not done what is required to show how so many Africans get HIV. In a closed-door meeting at WHO in 2003, John described HIV epidemiological research in Africa as: “First World researchers doing second class science in Third World countries.”

How will the medical research community rebuild competence after its deliberate incompetence in not explaining and thereby containing Africa’s AIDS epidemic?

John’s book offers much more than a history of HIV research failures. He and his staff at the Colorado Springs public health department reduced STD in the community. Working with researchers from CDC and elsewhere, they tested new control strategies and documented what works – demonstrating the importance of contact tracing and network analyses to understand and limit STD transmission. Research in Colorado Springs has had an impact on STD prevention programs around the world.

But this is not only history – the human costs of research failures are continuing. According to the latest UNAIDS’ estimate, 1.4 million Africans got HIV in 2014 (see: If someone could tell Africans how they are getting HIV, they might be able to protect themselves and collectively to wind down their epidemic.

I recommend the book for reading in epidemiology classes – to foster truthniks and doubters, so we will have the experts we need in future health crises. When you get the book, I recommend you start with a brief look at Appendix 3, which lists individual and STD/HIV program awards.

Charging HIV-positive husbands and wives with adultry — and lying about it

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Suppose a neighborhood gossip spread rumors a married woman was seeing lovers when her husband was at work, or that a married man had lovers? Suppose the gossip had no evidence, but was well paid to spread such rumors?

This situation threatens many HIV-positive married men and women in Africa. HIV prevention programs pay health care professionals to say most adults — including most HIV-positive married men and women with an HIV-negative partner — got it from lovers, even if there is no evidence they had lovers, and even if they deny it. Most health care professionals seem only too happy to play the role of malicious gossip.

For example, a UNAIDS-funded study in Zimbabwe followed adults to see who got HIV and what were their risks. The authors reported: “Thirteen of 67 individuals seroconverting in this study reported no sexual partners in the inter-survey period… This leads us to suspect that…misreporting of sexual behaviour may explain some of these infections…“[1]

Wife with HIV, husband without

Many women are victimized by such unsupported suspicions. National surveys in 24 African countries during 2010-14 report the percentages of couples with HIV in one or both partners. In 14 of 24 countries, if a married woman was HIV-positive, more than 50% of husbands were HIV-negative (Table 1). This is not explained by women getting HIV before marriage – even among married women aged 30-39 years, an HIV-positive wife was more likely to have an HIV-negative than an HIV-positive husband in 12 of 24 countries (Table 1).

Table 1: Among married HIV-positive women, the % of  husbands HIV-negative

wife+ husband-

Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: (from this link, click on the country and then the survey, and to the chapter that reports HIV prevalence).

Seeing such data, a World Bank economist, opines: “Sexual intercourse among women outside the marriage (or cohabiting union) may be more common than reported… [T]he contradiction between self-reported female behavior and the proportion of discordant female couples…suggests that self-reported behaviors are likely to be biased…”[2]

Most countries in Africa routinely test pregnant women for HIV. Hence, the wife is often the first partner to know her status. If the husband subsequently goes for a test, he is more likely to test HIV-negative than HIV-positive in most countries across Africa.

What is he to think? Should he believe his wife? Or should he believe health care professionals (behaving like paid gossips) who propose his wife lied about outside lovers? It is relevant, as well, that health care professionals have a conflict of interest – the alternative to blaming the wife for adultery is to acknowledge her infection could well have come from unsafe health care.

Husband with HIV, wife without

Similarly, blaming all HIV on sex encourages wives to blame HIV-positive husbands for having lovers and lying about it. In 15 of 24 countries, when the husband is HIV-positive, at least 50% of wives are HIV-negative (see Table 2).

Table 2: Among married HIV-positive men, the % of wives HIV-negative

husband+ wife-
Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: (from this link, click on the country and then the survey, and to the chapter that reports HIV prevalence).


1. Lopman, Garnett, Mason, Gregson. Individual level injection history: A lack of association with HIV incidence in rural Zimbabwe. PLoS 2008: Med 2(2): e37. Available at:


Cambodia: Partially reported outbreak in Roka Commune, but lots of other risks and unexplained infections

Roka Commune outbreak

According to newspaper reports, residents of Roka Commune in Cambodia began to suspect something was wrong in November 2014 when a 74-year old man tested HIV-positive. He sent his granddaughter and son-in-law for tests. They also tested positive. More residents went for tests; many were HIV-positive.

The next month, 24 December 2014, Cambodia’s Ministry of Health announced: “The Ministry of Health (MOH) of the Kingdom of Cambodia, with the support of the World Health Organization (WHO), US Centres for Disease Control and Prevention [CDC], UNAIDS, UNICEF and Pasteur Institute in Cambodia is investigating a number of HIV cases which have occurred among villagers from Roka village in Roka commune in Sangke district, Battambang province.”[1]

Strategy to avoid facing the problem: blame a scapegoat

What happened in Roka? The Government of Cambodia seems to have settled on a scapegoat. On 3 December 2015, a Cambodian court sentenced an unlicensed healthcare provider, Yem Chrin, to 25 years in jail for infecting more than 100 people with HIV.[2]

Strategy to avoid facing the problem: Incomplete investigation, incomplete report

Chrin’s sentencing left unanswered questions. For one thing, the numbers didn’t fit. Local newspapers put the total infected around 300. For another, the court did not wait for and use evidence from the joint Government-WHO-CDC-Institute Pasteur investigation[3].

The first substantial (but still partial) report from that investigation appeared two months later, in February 2016, in the US CDC’s Morbidity and Mortality Weekly Report[4].

  • As a part of that investigation, a case-control study “identified medical injections and infusions as the most likely modes of transmission.”
  • A test that can identify how long people have been infected [preliminary incidence assay] “suggested that 30% of infections in this outbreak could be classified as having occurred within the 130 days preceding specimen collection.” This points not only to rapid spread but also to high risk to transmit – effectively demolishing WHO’s oft-repeated estimated risk of 0.3% to transmit through reused syringes and needles.
  • As in many other nosocomial HIV outbreaks, children were on the front lines: 22% of cases were in children <14 years old.
  • More than 70% of HIV-positive samples tested for hepatitis C antibodies were found to have antibodies – similar to what one would expect to find in injection drug users who routinely reuse syringes and needles to inject illegal drugs.

The joint investigation and CDC’s February 2016 report are big improvements compared to the usual silence about patients’ risks, but still fall short of telling what happened so that an informed public and experts could work together to prevent and stop similar events in Cambodia and elsewhere — eg, Africa. The report:

  • does not discuss the specific procedures and errors that led to infections,
  • does not estimate rates of transmission through various procedures.
  • does not trace infections to specific healthcare settings, implicitly accepting what is likely a cover-up — blaming one unlicensed practitioner for the outbreak.
  • does not discuss infections in neighbouring communities, even ignoring infections that showed up in testing during the year.

Risks continue

A December 2015 BBC article – one year after Roka broke into public view – reports continued and common unsafe practices.[5]

A Westerner, who has worked in Cambodia’s health sector for many years says there is a general lack of knowledge about infection control throughout the country’s healthcare system. “I would say there are many more Rokas in Cambodia…The practices are so poor that it’s inevitable. I don’t think there’s a difference between licensed and unlicensed doctors. I think what we saw in this case was a breach of infection control practices [and] doctors working in the government sector get very little training – if any – in infection control.…People blame this HIV outbreak [in Roka] on an unlicensed practitioner. But it could be many practitioners, licensed or unlicensed, working for the government or not, who have bad practices which can end up with Hepatitis B, or Hep C, or HIV. If you aren’t aware of the problems then it’s harder to fix them.

Unexplained and uninvestigated infections continue

In mid-February 2016, an NGO reported 14 patients testing HIV-positive – 10 from Peam village in Kandal Province, a village of 1,000, and 4 from neighboring villages[6]. The article reported 32 previously known infections in Peam village, for a total of 42 or 4.2% of 1,000 villagers. In interviews, persons newly identified with HIV denied sexual risks and suspected infection from injections by a specified local doctor.  Cambodia’s Ministry of Health responded by testing 279 residents of Peam village; tests found 4 new infections. That would bring the total in Peam village to 46 or 4.6%. The number of Peam residents found with HIV is much greater than what could be expected from a 2005 national survey[7] reporting 0.6% of Cambodian adults to be HIV-positive; in Peam, that would be 3 infections only (0.6% of an estimated 500 adults out of a total population of 1,000).

The information I have been able to find does not report any effort to trace and test persons who visited suspected clinics, the ages of those tested, or the ages of those testing HIV-positive. Nevertheless, by early March 2016, Cambodia’s Ministry of Health and the World Health Organization (WHO) issued a joint statement denying an outbreak in Kandal Province[8].



See also these blogs posts


1. Eng Sarath. Ministry of Health, Cambodia. 24 December 2014. HIV cases in Sangke district, Battambang. Available at:

2. Kehumile Mazibuko. News Tonight Africa, 4 December 2015. Cambodia: unlicensed medical practitioner sentenced for infecting more than 100 people with HIV. Available at:

3. Khy Sovuthy, Anthony Jensen. Cambodia Daily, 8 December 2015. In HIV case, key evidence trails behind guilty verdict. Available at:

4. Mean Chhi Vun et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. Morbidity and Mortality Weekly Report 2016: 65:  142-145. Available at: (accessed 28 March 2016).

5. John Murphy. BBC, 17 December 2015. A country in love with injections and drips.
Available at:

6. Aun Pheap, George Wright. Doctor denies spreading HIV in latest outbreak. Cambodia Daily News 22 February 2016. Available at: (accessed 28 March 2016).

7. Cambodia Demographic and Health Survey 2005. Available at: (accessed 28 March 2016).

8. Hean Socheata. WHO, Phnom Penh: no regional outbreak. Voice of America 4 March 2016. Available at: (accessed 28 March 2016).


Why do UNICEF, WHO, and UNAIDS choose to stigmatize rather than protect African youth?

(go or return to first Prevention page)

Beginning in early 2015, UNICEF with UNAIDS, WHO, and other organizations initiated the All In to #EndAdolescentAIDS program. The program has some good points – e.g, asking for better treatment for HIV-positive adolescents.

However, the program is off the mark on HIV prevention. It says nothing about risks adolescents in Africa face to get HIV from blood-contaminated instruments during health care (blood tests, dental care, injections, etc) and cosmetic services (tattooing, manicures, hair styling).

Ignoring such risks while focusing only on sex stigmatizes those who are already infected (aha! you had careless sex!) and misleads those who are HIV-negative to ignore blood-borne risks.

Sex? The best available evidence – from national surveys – suggests less than half of HIV infections in African adolescents came from sex. For example, in national surveys in Kenya, Lesotho, and Tanzania, majorities of HIV-positive youth aged 15-19 years reported being virgins (Table 1). Across these three countries, 57% (36 of 63) HIV-positive youth in the survey samples reported being virgins.[1]

table 1 adolescents

Some virgins may have acquired HIV as babies from their mothers – but without antiretroviral treatment (ART), which arrived late in Africa, few babies with HIV survive to adolescence. Thus most adolescent virgins with HIV likely got it from blood contacts. If virgins are getting HIV that way, some non-virgins are likely getting it the same way — just because an HIV-positive adolescent had sex with one or more partners does not mean sex was the source of his or her HIV.

Using data from national surveys in Lesotho, Swaziland, and Zimbabwe, and assuming no lying about sexual behavior, Deuchert in a 2011 paper estimates only 30% of HIV-positive never-married adolescent women aged 15-19 years got HIV through sex.[2]

What if some lied? National surveys in Lesotho, Swaziland, Zimbabwe, and Zambia included 5,570 never-married women aged 15-19 years. Three percent (250) were HIV-positive, of which 116 (46%) reported being virgins. Even supposing that some women lied, a recent PhD dissertation estimates only 50% of infections came from sex (the author assumed some HIV-positive girls lied about being virgins, but this was more than offset by some non-virgins getting HIV from non-sexual risks).[3]

But let’s cast the net wider: Over the last 15 years, 45 national surveys in Africa reported %s of virgin and non-virgins youth aged 15-24 years with HIV (Table 2). Among those who said they weren’t virgins, the % with HIV was often no or only moderately greater than for self-reported virgins.

For example, in Congo (Brazzaville), Rwanda, Guinea (2012), Democratic Republic of the Congo, and Gambia, the % of young women HIV-positive was equal or higher among self-reported virgins than among all young women. Among young men, the % with HIV was the same or higher among virgins than among all young men in Tanzania (2007-08), Congo (Brazzaville), Sierra Leone (2013), Guinea (2oo5), Mali, Sao Tome and Principe, Burundi, Benin, Burkina Faso, Niger, and Gambia.

Across all 45 surveys, the median ratio of the %s of self-reported virgin young men with HIV to all young men with HIV was o.75 (last line, Table 2). Across all 45 surveys, the median ratio of the %s of self-reported virgin young women with HIV to all young women with HIV was 0.33 (last line, Table 2). And, as noted above, many infections in non-virgins likely came from bloodborne risks.

The only way to say most HIV infections in adolescents in Africa come from sex is to throw away the best evidence we have – to assume survey data are wrong because self-reported HIV-positive virgins are lying.

That seems to be what bureaucrats and experts at UNICEF, WHO, UNAIDS, and other international organizations have done – ignoring evidence to accuse HIV-positive adolescents of unwise sex, and accusing them also of lying if they say they are virgins.

Stigmatizing HIV-positive African youth for unwise sexual behavior is a form of abuse – not sexual abuse, but abuse nonetheless. Because young women are more likely than young men to be exposed to HIV during more frequent health care and cosmetic procedures, not warning about bloodborne risks contributes to unrecognized violence and abuse targeting African women.

table 2d adolescentstable 2e adolescents


1. Brewer DD, Potterat JJ, Muth SQ, Brody S. Converging evidence suggests nonsexual HIV transmission among adolescents in sub-Saharan Africa. J Adolescent Health 2007; 40: 290-293. Partial draft available at: (accessed 19 December 2015).

2. Deuchert E. The Virgin HIV Puzzle: Can Misreporting Account for the High Proportion of HIV Cases in Self-reported Virgins? Journal of African Economics, October 2011, pp 60-89. Abstract available at: (accessed 19 December 2015).

3. Tennekoon VSBW. Topics in health economics. PhD dissertation. Washington State U, 2012. Available at: (accessed 18 December 2015). See also an earlier paper by






Adding insult to injury: Why do healthcare professionals stigmatize victims of unsafe healthcare with accusations of sexual promiscuity?

I can’t answer the question in the title, and I don’t want an answer. What I want is that healthcare pros stop sliming suffering people with unsupported suspicions and accusations.

In a recent example of this reprehensible behavior, a senior member of Liberia’s Ebola Case Management Team speculated that a Liberian woman identified with Ebola in mid-March – several weeks after the last previous Liberian tested positive for Ebola – might have “had sex with a survivor” (

The infected woman has 5 children and a modest job – selling food in the market ( Having Ebola is a heavy burden for the woman and her family and a threat to her neighbors. For her to be slimed in public – by a government official speculating about her sexual behavior – can only add to their sorrow and confusion.

What is the most likely source of her infection? Based on more than 20 Ebola outbreaks from 1976 to 2015, if the woman has not been caring for someone with Ebola (she hasn’t), she most likely got it from attending a healthcare facility that reused instruments without sterilization. Hundreds of cases of Ebola have been documented from unsafe healthcare, while no – none, nada, zero – cases of Ebola have been traced to sex with a survivor.

Is Liberia’s Ebola Case Management Team considering the possibility the woman got Ebola from a healthcare facility? Very likely, yes. Whereas the Ebola outbreak continues in Sierra Leone and Guinea, Liberia’s outbreak is over or nearly so. Such success is evidence that Liberia’s Ebola Team is competent – that it has recognized and addressed patients’ risks to get Ebola in hospitals and clinics.

Competent, yes, and that’s important. But the Team has been and continues to be unethical in not acknowledging such risks to the public.

A similar assessment applies to experts dealing with HIV in Africa. Consider, for example, that roughly 50% of married HIV-positive women in Africa – over 80% in the Democratic Republic of Congo and Sierra Leone – have HIV-negative husbands (data from Demographic and Health Surveys available at:

Healthcare pros’ repeated assertions that sex is the source of almost all HIV infections in Africa charge all such women with extramarital sex, a charge that is a slur in many cultures. Such sliming is a de facto policy. Virtually all organizations that bankroll HIV prevention in Africa — UNAIDS, WHO, USAID, Gates, and others – require people they fund to aver that almost all HIV infections in Africa come from sex.

Many healthcare pros knowledgeable about HIV are aware of such nonsense. Those who speak out – who are both competent and ethical – have no chance to work on HIV in Africa. They are pushed aside in favor of others who are either ignorant or unethical (or both).

WHO promotes safe injections, but continues to underestimate bloodborne risks

On 23 February, WHO announced its intention to promote auto-disable syringes for curative injections[1]. This is a hugely encouraging response to an HIV outbreak discovered in Roka village, Cambodia, in December 2014 – hundreds of villagers infected through unsafe healthcare.

Unfortunately, WHO’s press release announcing its commitment to promote auto-disable syringes low-balled the risk to get HIV from unsafe health care. The press release cited a recent WHO-sponsored study[2] that estimated unsafe medical injections accounted for less than 1.3% of HIV transmissions in the world in 2010. The authors of that WHO-sponsored study calculated their estimates using a model that depends crucially on an assumed low rate of HIV transmission through contaminated syringes and needles. The authors assumed that if a doctor or nurse injects someone with HIV and then reuses the same syringe and needle – without boiling them – to give you an injection, your risk to get HIV is only 0.32%-0.64%. To support such an assumed low risk, the authors cited similar assumptions from other papers and authors – all of which ignored and/or rejected evidence of transmission during actual outbreaks where medical injections transmitted HIV.

The outbreak in Roka, Cambodia, gives us a chance to test these low-ball assumptions. If the risk to transmit HIV from an HIV-infected patient to a later patient through reused, unsterilized syringes and needles was 0.32%-0.64% only, someone infected with HIV would have to have, on average, 156 (=1/0.0064) to 313 (=1/0.0032) injections after which equipment was reused without sterilization to infect one other person. If the average person living with HIV got 15 injections per year (an absurdly large figure) it would take an average of 10 to 20 years for him or her to transmit HIV to one other person through unsafe injections. People living with HIV would, on average, die before infecting someone through an unsafe injection.

In short, with the transmission efficiencies Pepin and colleagues assumed (in the study cited by WHO’s press release), the outbreak in Roka, Cambodia, was impossible.

For decades, health care authorities who could stop transmission of HIV in health care have chosen not to do so. They have chosen to stick their heads in the sand, to accept ridiculously low assumptions about HIV transmission efficiencies through contaminated instruments, not to warn patients at risk, to give deceitful assurances, etc.

WHO’s endorsement of auto-disable syringes is a step in the right direction. Much more is required to change the trajectory of largely unnecessary and easily preventable HIV epidemics in Africa – eg, outbreak investigations, acknowledging common risks in formal as well as informal health care settings, etc.

1. WHO. WHO calls for worldwide use of “smart” syringes. Press release 23 February 2015. Available at: (accessed 24 February 2015).

2. Pepin J, Abou Chakra CN, Pepin E, Nault V, Valiquette L (2014) Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010. PLoS ONE 9(6): e99677. doi:10.1371/journal.pone.0099677. Available at: (accessed 24 February 2015).

Cambodian HIV tragedy: Investigate to treat, protect, and prevent HIV

On 16 December, newspapers reported more than 80 residents of a Cambodian village had tested HIV-positive in recent weeks. As of 20 December the reported number testing positive reached 140. Testing is continuing, so that number will likely increase further.

“The crisis began in late November, when a 74-year-old man from Roka tested positive for HIV at the Roka Health Center, according to a statement from Cambodia’s Ministry of Health and the World Health Organization. After receiving the result, the man then sent his granddaughter and son-in-law for testing. They also tested positive for the virus. The man then informed other villagers who had been treated by [an unregistered doctor] to get tested for HIV. After that, the number of cases steadily rose” (quote from:

Outbreaks such as this are not unusual (see: What is unusual is that this one is recognized. It will be even more unusual if it is thoroughly investigated and reported.

An investigation can limit health damage.
1. Limit damage to the victims. Test widely to find as many victims as possible. Then ensure they get good treatment so they can look forward to a near-normal life.
2. Limit damage to others. Investigate to find the specific risks so they can be stopped, not only in this village but in thousands of similar situations in Asia and Africa. Did HIV go through saline infusions, intra-muscular injections, vaccinations, what? When the routes are identified in this outbreak, tell the public at risk in Cambodia and elsewhere so they can help to develop responses to protect themselves and others.

These two challenges can be satisfied with a no-fault investigation. The investigation could be modeled on a truth commission. People who might have been involved in transmission can be asked to cooperate – to report (confess) procedures that might have been unsafe and to report who they treated – in return for a promise not to prosecute.

What can be distracting in an investigation are efforts to pin the blame on one or more people, to put them in prison or sue them. Fear closes doors – what we need are open doors to find what went wrong and fix it. Yes, there is a lot of careless behavior in clinics and hospital – but many who are careless do not realize the risks because they have been confused by lies, eg, that HIV dies in seconds outside the body.

If careless people are to be prosecuted, should we start at the top? Leaders of the health aid industry know health care is often unsafe in much of Asia and Africa and yet support the delivery of invasive procedures without warning the public and without insisting on outbreak investigations to find and stop careless errors. Since it’s unlikely anyone will try to prosecute people at the top, let’s not scapegoat people at the bottom for careless behavior.

A good example of a failed investigation is what happened in Jalalpur Jattan, Pakistan, six years ago (see: In 2008, a local NGO tested 246 people in the community, finding 88 to be infected. This got the attention of Pakistan’s National Institute of Health, which assigned Pakistan’s Field Epidemiology & Laboratory Training Program (FELTP) to investigate, with assistance from the US Centers for Disease Control and Prevention (CDC). The Government charged FELTP to: “determine the extent and chain of transmission” and to “identify…sites of potential transmission.”

FELPT’s investigators did neither. They began with a list of 20 HIV-positive people provided by the government hospital, traced relatives, and looked for people with stigmatized behaviors (sex work, male-male sex, injection drug use). Because the “investigation” did not test the general population it could not determine the extent of transmission or sites of transmission. The report added insult to injury with stigmatizing sexual fantasies: “there may be hidden extramarital and unsafe sexual practices in the community which were difficult to unveil” (see p 51 in:

In Cambodia, let’s hope for an investigation that prioritizes finding and caring for victims (see: and preventing more victims – and that does not insult victims with accusations of stigmatized behaviors.

Good news from Liberia: Why?

Reported deaths from Ebola peaked in Liberia in the week ending 2 September,[1] falling to 35 per day during 12-18 October (see WHO Situation Reports for 15 and 25 October[2]). As early as 9 October, National Public Radio in the US noted that reported Ebola cases in Liberia had fallen by “about 160 cases each week” from end-September.[3] According to a 23 October news report,[4] “Virtually everyone in Liberia agrees on a new, stunning fact: Ebola cases in Liberia are dropping.”

Why has the outbreak apparently peaked and fallen back in Liberia, while the outbreak in Sierra Leone has stampeded ahead for at least another month? The answer to that question is relevant to ongoing and anticipated well-funded public health interventions aimed at the outbreak.

Gene studies suggest Ebola has been around for at least 1,200 years[5] and possibly much, much longer.[6] Presumably thousands of Africans over the centuries have gotten Ebola from the wild, eg, by getting blood into cuts while butchering infected chimpanzees. The absence of recognized outbreaks before 1976 is strong evidence transmission during home-based care and funerals is not enough to sustain, much less amplify, outbreaks. Before 1976, people that were somehow infected with Ebola on average infected less than one other person.

Similarly, in well-documented Ebola outbreaks beginning in 1976, transmission within the household and during funerals has not been enough to sustain outbreaks. Amplification of infections in health care settings – transmission from patients to care-givers and to other patients – has multiplied otherwise rare infections to the point that outbreaks are recognized.

Once recognized, most of the more than 20 outbreaks to date ended within 1-3 months.
Only one continued beyond 4 months – an outbreak, in Gabon in 2001-2, continued 5 months and 5 days.[5] The common pattern of interventions ending outbreaks to date has been to somehow stop health facilities from amplifying infections – to prevent Ebola transmission to health care workers and other patients.

A mission hospital near the Ebola River in Zaire amplified the eponymous Ebola outbreak in 1976. Injections with reused and unsterile syringes and needles infected at least 85 of the 280 who died[7] and – through secondary infections among contacts – were directly or indirectly responsible for most deaths. The hospital closed after Ebola sickened or killed most of its staff. Although this was a sorry way to stop the hospital from further amplifying the outbreak, it was effective. After the hospital closed, the outbreak ended with home-based care before an international health aid team even began to search for cases.

During the ongoing West Africa outbreak, the health aid community has acknowledged that hospitals are dangerous places for health care workers. WHO’s Situation Report for 22 October[2] reports 440 cases and 244 deaths among health care workers in West Africa and Nigeria through 19 October. The health aid community has commendably committed hundreds of millions of dollars in equipment and training to stop transmissions to health care staff.

However, to stop hospitals from amplifying infections, patients and not only health care workers must be protected – eg, instruments must be sterilized and gloves changed between patients. If anything is being done along these lines, there is no news. The health aid community has said next to nothing about transmissions to patients in Guinea, Liberia, and Sierra Leone – has any account been made but not reported? – and Ebola prevention messages for the general public have been silent about patients’ risks. Better reporting from Nigeria very clearly shows hospital amplification to health staff and patients: An index case flying in from Liberia started a mini-outbreak that infected 19 Nigerians – 16 acquired Ebola during health care (12 health staff and 4 patients) and 3 of these 16 infected one relative each.[8]

Even if public health authorities are silent about patients’ risks to get Ebola during health care, people will learn of such infections through friends and rumors. When people avoid health facilities because they fear to get Ebola, or don’t want to be cremated or buried in unmarked graves, this reduces amplification of infections in health facilities. When doctors and nurses stay home or refuse to treat patients out of fear, this also protects patients. Some anecdotal reports suggest that such behaviors have been common in Liberia.

Previous Ebola outbreaks warn that health care in hospitals, not home-based care, is the biggest risk to sustain and amplify outbreaks. How much has public avoidance of health care facilities contributed to reducing Ebola transmission in Liberia? Conversely, how much did public health efforts to bring suspected and confirmed cases into hospitals beginning in March contribute to outbreak amplification in Liberia through August?

Maybe the current outbreak in West Africa is different – maybe patients cared for at home are responsible for outbreak amplification, while hospitals have been dampening the outbreak. Maybe. On the other hand, if transmission during this outbreak is similar to previous outbreaks, the massive funds provided to stem the epidemic present a promise and a threat. If patients are protected, aid-financed expansion of health facilities could save lives. On the other hand, if patients are not protected, bringing more suspected and confirmed cases into hospitals could impede rather than speed the end of the outbreak.

5. Chippaux, Outbreaks of Ebola virus disease in Africa…, available at:
6. Taylor et al, Evidence that ebolaviruses…Miocene, available at:
7. International Commission, Ebola haemorrhagic fever in Zaire, 1976, available at:
8. Fasina et al, Transmission dynamics…Nigeria, available at:

How is Ebola transmitted in the ongoing West African outbreak?

Getting an answer to the question in the title is crucial for people in countries with ongoing epidemics – to protect themselves they need to know the ways they are most likely to get Ebola. The answer is important for people in other African countries as well – to help them assess the probability the epidemic will reach their country, and to prepare for this possibility.

People outside Africa also need the answer. Politicians and bureaucrats who vote and manage aid funds can make better decisions with a clear account of whether and how what they are paying for is saving lives. Finally, although there is only an outside chance the virus has changed or will change to transmit more efficiently, that small possibility represents big risks to people around the world. We want to know what’s happening.

There are two steps for health aid managers to answer the question in the title. They must:
• Get the answer through surveillance.
• Report what they find to the general public.

As of September 2014, public health experts have not reported the relative contribution of various exposures in transmitting Ebola in the current outbreak. Their failure to do so may be due to missing the first step (ie, they don’t know) or the second (ie, they know but don’t say).

Contact tracing to find the source of infections

The public health response to West Africa’s Ebola epidemic includes a lot of effort to trace contacts of people with Ebola to identify new cases as soon as possible – as soon as they get symptoms. For example, at end-August, “WHO and its partners are on the ground establishing Ebola treatment centres and strengthening capacity for…contact tracing…” (WHO, Ebola virus disease update, 28 August, at:

However, I have found no reports of contact tracing to find where and how people with Ebola got their infections. How to do this is straightforward: Ask people with new Ebola infections if they had touched someone who was sick or if they had attended a funeral in the previous 21 days; touching someone sick or dead with Ebola is a recognized risk. Ask if they got injections, infusions, or any other skin-piercing procedure in the previous 21 days; such procedures are also recognized risks. Then trace contacts and visit and investigate reported health care settings.

If more than a few people with new infections report no contacts with other cases and no skin-piercing procedures, that is cause for concern and, more critically, further investigation. Such unexplained cases could be showing the virus is transmitting in unexpected ways.

John Potterat has been a practitioner and advocate of contract tracing and partner notification as a public health tool to understand and control the spread of infectious diseases. In a recent article on partner notification for HIV in Africa, written before the explosion of West Africa’s Ebola outbreak, Potterat presciently recommends the skills required to diagnose what has allowed that outbreak to grow: “Nurturing public health investigatory (and people and community rela¬tions) skills that one can acquire by conducting PN [partner notification] would be of great service anywhere that new communicable infections or public health emergencies are likely to emerge” (–article-a4370-abstract).

Telling people what is happening

This second step to answer the question in the title is not automatic. Based on reports from previous Ebola outbreaks, patient-to-patient transmission in health care settings – eg, through injections with contaminated syringes and needles – contributes to expanding outbreaks. Considering the persistent expansion of the ongoing Ebola outbreak in West Africa, it is probable that patient-to-patient transmission plays an important part. If anyone has such information, they have not disclosed it.

In Africa, it has been common practice for ministries of health – encouraged by health aid managers – not to disclose evidence that patients have gotten blood-borne infections such as HIV from unsterile health care procedures. Not warning the public is excused by the assertion that warning might cause more harm than it would prevent: the infections prevented would be outweighed by disease and death due to patients avoiding health care.

Such body count calculations ignore doctors’ ethical obligations. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient avers: “1d. Quality assurance should always be a part of health care… 9. Every person has the right to health education that will assist him/her in making informed choices about…the available health services…” (see:

Furthermore, the assertion is based on a misleading mention of only two options – no health care vs. unsafe care. But there is a third option – safe care. Getting to the third option is not, primarily, a matter of money. It costs little or nothing to avoid unnecessary invasive procedures, shift to oral medication, boil instruments, or use plastic disposables. What is lacking is public awareness – lacking due to misinformation by ministries of health and health aid managers.

If ministry officials and/or health aid managers have evidence that people have gotten Ebola infections from health care procedures and settings during the current outbreak, will they tell the public?

Will concern to stop West Africa’s outbreak over-ride public health managers’ unwillingness to warn the public about risks in health care settings? Will the world public’s interest to know if the virus is changing over-ride health aid managers’ unwillingness to acknowledge the contribution of unsafe health care to the current outbreak?

Intersection between HIV and Ebola in Africa

A long history of unsafe health care

During the 20th century and continuing, millions of Africans have gotten blood-borne infections, including tetanus, hepatitis B, hepatitis C, HIV, and Ebola, from unsafe healthcare. With some exceptions, the health aid community’s response has been to deny that health care accounts for more than minorities of blood-borne infections. Instead of fixing unsafe procedures, the health aid community’s repeated response has been to promote solutions involving more invasive procedures.

For example, women and infants in Africa were observed to get tetanus infections from unsterile and contaminated instruments during childbirth. The health aid community responded with tetanus vaccinations – arranging for young women to get as many as five more injections, and for babies to be injected at birth. Vaccinations protect mothers and babies from tetanus, but because additional injections are not reliably sterile, an unknown number get other blood-borne infections.

Across much of Africa in the late 20th century, 70%-95% of adults had been infected with hepatitis B at some time in their lives, while 7%-15% had continuing (chronic) infections. Most chronic infections came from exposures during infancy or early childhood. Studies in Africa reported as many as 50% of children infected before their 5th birthday. The health aid community denied an important role for unsterile health care. Instead of making sure children received safe care, the health aid community introduced another injected vaccine to protect them from hepatitis B. Vaccinations currently protect many Africans from hepatitis B but increase their risk for other blood-borne infections.

Enter HIV. Recent mainstream research traces the origin of the world’s HIV epidemic to colonial health care programs spreading a rare HIV infection (from an otherwise self-limiting outbreak, likely beginning from a chimp butchered for bush meat) to thousands of Africans through unsterile injections for sleeping sickness, yaws, and suspected sexual infections. A lot of evidence suggests blood-borne transmission continues to drive Africa’s peculiar HIV epidemics. Unlike epidemics in almost all countries outside Africa, women in Africa are infected more often than men. Outside Africa, HIV is rare except in adults who inject illegal drugs and men who have sex with men; whereas in much of Eastern and Southern Africa, as many as 20%-50% of adults, most with conservative sex lives and often an HIV-negative spouse, can expect to get HIV during their lifetime.

Missing an opportunity to find and fix unsafe health care

In 1988, Russia investigated an unexplained HIV infection in a child with an HIV-negative mother – thereby uncovering and stopping a chain of transmission through unsterile procedures in 13 hospitals that spread HIV from one to 265 children in 15 months. Several years later, tests in four African cities (Kampala, Kigali, Lusaka, and Dar es Salaam) on 5,593 inpatient children and their mothers found 61 children (1.1%) to be HIV-positive with HIV-negative mothers. Instead of initiating investigations, WHO staff blithely and incredibly concluded “the risk of…patient-to-patient transmission of HIV among children in health care settings is low” (p. 85, 1992-1993 Progress Report, Global Programme on AIDS).

The health aid community has spent billions on HIV prevention messages for Africans focusing almost exclusively on sexual risks. Such messages, with their roots in European and American racial prejudices, smear all Africans – including millions of HIV-positive married women with HIV-negative husbands – with suspicions of uncontrolled sexual behavior.

Although the health aid community has done its best to ignore HIV from unsafe health care in Africa, the US Congress has not only been aware of the problem, but has also made available billions of dollars to fix it. In 2003, the US Congress pressed USAID and CDC to spend $300 million allocated for HIV prevention to improve injection safety and blood safety, primarily in Africa. In 2008, when Congress approved $48 billion for HIV aid, primarily for Africa (see:, it asked the President to develop a 5-year strategy, including (page 8): “(C) promoting universal precautions in formal and informal health care settings; (D) educating the public to recognize and to avoid risks to contract HIV through blood exposures during formal and informal health care and cosmetic services; (E) investigating suspected nosocomial infections to identify and stop further nosocomial transmission…”

At the same time, Congress (page 39) asked the US Global AIDS Coordinator to submit an annual report assessing impact on “capacity to identify, investigate, and stop nosocomial transmission of infectious diseases, including HIV and tuberculosis…” Regrettably, during 2008-13, USAID and CDC spent nothing on outbreak investigations in Africa or to warn the public about blood-borne risks. Instead, USAID and CDC promoted more invasive procedures – male circumcision in unreliably sterile conditions – to reduce HIV infections.

Ebola shines a spot-light to unsafe health care

In 2014, West Africa’s Ebola outbreak exposed unsafe health care systems. Health aid managers were quick to acknowledge that health staff are at risk – this was impossible to deny as more than 100 doctors and nurses died. On the other hand, health aid managers have been silent about patients getting Ebola from unsafe health care.

Health aid managers have for decades been able to get away with a head-in-the-sand response to HIV from unsafe health care. This has been possible because HIV infections from health care are relatively easy to ignore – most victims don’t recognize their infections, which are silent for years. Even when unsafe health care fuels atrocious HIV epidemics, health aid managers have been able to divert attention, adding insult to injury, by blaming infections on victims’ supposed sexual misbehaviors.

With Ebola as with HIV, health aid managers are faced with the choice between warning the public to be wary of skin-piercing health care procedures or staying silent about the risk and thereby allowing preventable infections. With HIV, health aid managers’ have chosen to deny problems, even at the cost of millions of unnecessary infections. With Ebola, however, health aid managers may not have that option. People who see family members, friends, and neighbors get Ebola within days after health care procedures may demand action to find and stop unsafe health care procedures.

If West Africa’s current Ebola outbreak gets people to see and stop reuse of unsterile instruments in health care, the beneficial consequences of the current outbreak – fewer HIV and other blood-borne infections – could far outweigh its current terrible human costs.