Don't Get Stuck With HIV

Protect yourself from HIV during healthcare and cosmetic services

More unexplained HIV infections in KwaZulu-Natal: time to investigate!


Background: Beginning in 2004, the Africa Health Research Institute in KwaZulu-Natal, South Africa, has been testing a random sample of adults for HIV infection in a study area extending about 21 km x 21 km northwest of Mtubatuba town. The study area has one of the worst HIV epidemics in the world: as of 2014, 36% of women and 27% of men aged ≥15 years were infected (about 9,000 out of 30,000 adults)[1,2].

Recently, the Institute “sequenced” HIV (determined the order of small molecules in each HIV) from 1,376 adults in the study area. From these sequences, the Institute found a group (cluster) of 63 very similar sequences. Because HIV sequences change over time, if a cluster of sequences are almost the same, it means HIV from one person not long ago infected everyone in the cluster.

How long did it take for HIV from one person to infect 63 people? The Institute estimated it took one year only, from mid-2013 to mid-2014 for HIV to pass from one person directly and indirectly (through others, in short transmission chains) to 63 people (see the large cluster in the upper right in slide 10 of Coltart’s 2018 presentation).[3]

To go from 1 to 63 infections in 12 months the number of infections doubled almost 6 times – doubling on average every 2 months from 1 to 2 infections, 2 to 4 infections, etc, to 63 infections. Everything we know about sexual transmission of HIV says sex doesn’t do that! With hetero sex, it takes on average 1,000 coital acts for one person to infect another; that takes a lot more than 2 months. Even for male-male sex, it takes ≥30 penis-in-anus events for one transmission; that also takes time.

Such fast transmission is possible when hospitals or clinics reuse unsterilized skin-piercing instruments. Governments investigating unexplained HIV infections have found such tragedies in Russia, Romania, Libya, and other countries.

The cluster of 63 sequences in KwaZulu-Natal looks like a cluster of sequences from an investigated outbreak in Roka, Cambodia: In late 2014, several residents in Roka, a rural community in Cambodia, found they were HIV-positive although they had no sex risks. The Cambodian government investigated, testing all people in the community. The investigation found 242 HIV-positive residents and traced most infections to injections and other skin-piercing procedures from a local private healthcare provider.

Foreign organizations helping with the investigation sequenced several hundred HIV from the community. Almost all sequences were very similar, showing fast transmission from 1 to 198 infections in a few short years. These sequences can be presented as branches in a “tree” (Figure 1, below[4]). The upper right section of the tree shows the cluster of very similar sequences from Roka. (Most sequences in the lower part of the tree are “controls,” which means the HIV came from other times and places.) The tree shows each HIV infection as the right end-point of a horizontal line. The left ends of these lines show estimated connections to earlier estimated infections. Because the cluster includes very recent infections only, all lines in the upper right are very short. The timeline at the bottom of the figure shows time going from left to right, showing the estimated dates of transmission from earlier to later infections.

Figure 1: Cluster of 198 infections in Roka, Cambodia, linked by transmissions during 2011-14[4]

env_timetree_baltic (1)

If 63 sequences from KwaZulu-Natal came from unsafe healthcare, how many people got infected in the outbreak? The cluster of 63 HIV sequences (see slide 10) is from a 15% sample of HIV-positive adults in the study area (1,347 out of an estimated 9,000 infected adults). If someone could sequence HIV from all 9,000, one could expect to find 420 (= 63/0.15) sequences in the cluster, all from people with new and closely linked infections. Moreover, many of the 63 infections came from Mtubaba town on the southwest edge of the study area. If a hospital or clinic in Mtubatuba town was infecting patients, it’s likely the outbreak also extends south and east of the town. Hence, the number of people infected from whatever caused the cluster might well exceed 1,000. And transmission looked like it was continuing when the Institute collected the last HIV samples it sequenced (see slide 10).

What’s the response to this evidence? Investigating the cluster – to find all who have been infected in the outbreak and to find and stop the sources – is a job for public health. As long as the sources of unexpected infections are not found and stopped, public health should also be warning people about blood-borne risks.

If the South African government were to investigate, what could it do? A first task would be to interview people in the cluster to find where they got health care, dental care, tattooing, or other skin-piercing procedures in 2013-14. Once one or more facilities are identified as the possible sources of at least some infections, public health staff could visit the facilities to look for – and fix – dangerous mistakes. At the same time, government could make a public request for people who got skin-piercing procedures at suspected facilities to come for tests. If someone is infected, start treatment. At the same time, investigators could sequence their HIV to see if it’s similar to HIV in the cluster.

References

1. Vandormael A, Barnighausen T, Herbeck J, et al. Longitudinal trends in the prevalence of detectable HIV viremia: population-based evidence from rural KwaZulu-Natal, South Africa. Clin Infect Dis 2018; 66: 1254-1260. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/29186391 (accessed 16 November 2018).

2. Larmarange J, Mossong J, Barnighausen T, et al. Participation dynamics in population-based longitudinal HIV surveillance in rural South Africa. PLoS ONE 2015; 10: e012345. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0123345 (accessed 16 November 2018).

3. Slide 10 in: Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&&crd_fl=0&ssmsrq=1522772955419&ctms=5000&csmsrq=5001 (accessed 4 April 2018).

4. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/ (accessed 15 November 2018). This figure has been copied by permission from Bedford Lab.

Unexplained HIV infections in KwaZulu-Natal: Time to investigate?


It’s decades too late to prevent Africa’s HIV epidemics. But it’s not too late to stop them! When will politicians tell ministries of health to investigate unexpected HIV infections?

There are many places to begin. Here’s one. An article in the journal Lancet HIV, August 2018, reported results from a 2014-15 survey in uMgungundlovu district, KwaZulu-Natal, South Africa.[1] Among women, 44.1% of adults were HIV-positive, including 66.4% of women aged 35-39 years. As for men, 28.0% of adults were infected, including 59.6% of men aged 40-44 years.

Compare this to what happens outside Africa: 0.3% (3 in 1,000) of adults are infected,[2] about half of which are injection drug users and men who have sex with men.

Why do adults in KwaZulu-Natal have hundreds of times more HIV than low risk adults outside Africa? What’s different?

One clue from the survey is that 11.2% of (self-reported) virgin women were HIV-positive, as were 9.0% of (self-reported) virgin men. Another clue is that the percent of young women with HIV increased precipitously: by 34% in 8 years only, from 6.0% at 15-16 years to 40.1% at 23-24 years. The authors want to blame this on sex. But sex can’t explain it: 3/5ths of surveyed women started having sex at age 18 years or later; more than 95% who reported sex in the previous year reported only one partner; and less than 15% lived with a man, making it convenient for them to have frequent sex.

What else could it be? It’s time to take a good look at unexplained HIV (11% of virgin women had unexplained HIV!) to see if such infections came from unsafe healthcare. Beginning in 1988, governments outside Africa have investigated unexplained infections to uncover HIV outbreaks from healthcare with hundreds to thousands of victims.

So far, there have been no such investigations in Africa. But year-by-year, with more HIV testing, more men and women are finding they are HIV positive despite no sex risks. Will increasing public awareness of unexplained infections in KwaZulu-Natal and elsewhere in Africa translate into public demands to investigate?

Finding the hospital or clinic that infected a particular patient is not enough. Once a facility is suspected to have infected one person, it’s important to invite other patients to come for tests, and to report findings to the public. Finding all the people infected in an outbreak can identify unexpected risks. Openness and honesty is the way to go. Telling the public generates support for safe care. Punishing specific healthcare workers can be a distracting witch hunt – in an outbreak, it’s likely many doctors and nurses infected patients due to ignorance, thinking what they did was safe, not from any intent to harm. Finding and fixing mistakes should be the priority.

References

1. Kharsany ABM, Cawood C, Khanyile D, et al. Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey. Lancet HIV 2018; 5: e 427-e437. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/30021700 (accessed 23 October 2018).

 

AIDS: Prevention of nosocomial infections


Authors: Jäger H, Gisselquist D [this blog was originally posted on 27 July 2018 at: http://www.medizinisches-coaching.net/aids-nosocomial.html%5D

Introduction

Transmission of HIV through health care facilities has been neglected in the fight against HIV/AIDS. The 2018 World AIDS Conference ignored health care risks that have been described in detail for decades (Gonzac 2008Grimm 2011Goldwater 2013), and also outbreak events such as in Cambodia from 2014-2015 (Rouet 2018).

Would it be useful to pay more attention to the subject? ” … the decision of WHO, Western researchers, and the media to ignore the role of reuse of contaminated syringes and needles in health care settings and to instead emphasize African people’s sex with multiple partners was .. critical in the explosion of HIV in Africa … If iatrogenic transmissions had been taken seriously and addressed early, HIV in Africa would have been different (Fernando 2018).”

Why Africa?

Four countries with 0.8% of the world’s population – South Africa, Botswana, Lesotho, and Swaziland – have 21% of the world’s HIV infections (2016 data, UNAIDS 2017). Adult HIV prevalence was 27.2% in Swaziland, 25% in Lesotho, 21.9% in Botswana, and 18.9% in South Africa. In the same year, all of sub-Saharan Africa had 69% of the world’s HIV infections (25.4 of 37.6 million), including 80% of infections in women (14.1 of 17.8 million). HIV not only infects more people in Africa, but also more women: the ratio of women to men with HIV is 1.5 in Africa, whereas in the rest of the world it’s 0.52.

Surveys find sexual behaviour in Africa is similar or safer than in Europe. Can risks other than sex explain why so many people in Africa get HIV?

Lots of evidence says: Yes.

Beginning in the mid-1980s, most official HIV/AIDS experts have ignored abundant evidence unsafe healthcare risks transmit HIV in Africa (Potterat 2016). For example, over 12 weeks in June-August 1985, Project SIDA in Zaire (Democratic Republic of the Congo) tested 258 in-patient children aged 2-24 months at Mama Yemo Hospital in Kinshasa and their mothers for HIV; 32 children were HIV-positive, of which 16 had HIV-negative mothers. The paper that reported these infections noted that children had received injections (p 656, Mann 1986) “in dispensaries which reuse needles and syringes yet may not adequately sterilize their injection equipment.” But there was no investigation – no call for other children to come for tests, and no report of steps taken to prevent future infections.

Another paper by three of the same authors shows the thinking behind the failure to investigate (p 962, Quinn 1986): “one cannot hope to prevent reuse of disposable injection equipment when many hospital budgets are insufficient for the purchase of antibiotics.” In effect, the authors accepted an unknown frequency of nosocomial HIV transmission in Mama Yemo Hospital and elsewhere in Africa. The authors of these two papers include leaders of the international response to AIDS for 22 years: Jonathan Mann led WHO’s Global Program on AIDS during 1986-90; and Peter Piot led UNAIDS during 1995-2008.

Over the years, there has been a continuing flood of evidence for unsafe healthcare and nosocomial HIV transmission in Africa. Jaeger (1991) and N’tita (1991) detailed risks with untested blood and unsterile instruments and procedures. Beginning from 1999, USAID has worked with African governments to survey health facilities: during 2006-15, surveys in six countries in East and Southern Africa reported that 17%-88% (median 68%) of clinics, dispensaries, health centers, and hospitals had equipment to sterilize instruments (USAID no date).

Beginning from 2001, USAID has worked with African governments to test random samples of adults (and sometimes children) for HIV; tests are coupled with questions about sexual behavior. During 2004-15, 11 surveys in Swaziland, Lesotho, Namibia, Zimbabwe, Zambia, and Mozambique reported HIV infections in self-declared virgins: in 11 surveys; across all 11 surveys, 2.2%-5.5% (median 3.6%) of self-declared virgin women and 0.6%-6.7% (median 3.1%) of self-declared virgin men were HIV-positive. In 2006, 22% of HIV-positive children aged 2-11 years in Swaziland had mothers who tested HIV-negative (Okinyi 2009); in Mozambique, 28% of HIV-positive children aged 0-11 years had mothers who tested HIV-negative (USAID no date).

In a 2012 survey of more than 3,000 high school students aged 12->20 years in KwaZulu-Natal, 6.2% of girls and 2.5% of boys were HIV-positive. More than half of the HIV-positive girls and boys said they were virgins (Kharsany, 2014).

A phylogenetic analysis of 1,376 HIV samples collected during 2010-14 from a random sample of adults in KwaZulu-Natal found a large cluster of 75 sequences, including a sub-cluster of more than 60 sequences. Phylogenetic analysis estimated all infections in the sub-cluster were acquired over 12 months from mid-2013 to mid-2014 (Coltart, 2018). Because the study sequenced an estimated 15% of HIV from adults in the community, and because the cluster likely extended beyond the sampled population, the number of infections in the sub-cluster in mid-2014 was likely well over 500; because transmission was ongoing when the samples were collected, whatever was causing the sub-cluster may have continued to infect hundreds more. Rapid transmission within this sub-cluster – much too fast to be explained by sexual transmission – is similar to what investigations have found in nosocomial outbreaks in Russia, Romania, Libya, Cambodia, and elsewhere.

In 2011, Grimm and Class (2011) urged Germany’s Development Bank (KfW) to pay attention to evidence “an important share of new infections in high prevalence settings occurs through blood exposures in formal and informal healthcare,” and called for “interventions targeted to strengthening the health care system in general and infection control in particular.”

When asked on 22 December 2017, what conclusions KfW drew from that paper, Patrick Rudolph, Sector Policy Unit Health & Social Protection, KfW, responded on 19 January 2018: “… In South Africa – currently the only country in which the fight against HIV is the focus of German development cooperation in the health sector – the focus is clearly on preventing the sexual transmission of the pathogen …” But how can he be so sure that HIV proliferation in South Africa can only be explained by sexual activity?

Apart from risky sexual contacts, people in Africa as well as in other countries with less intense generalized HIV epidemics face many other risks, including:

  • Unsterile and often unnecessary medical procedures
  • Cosmetic services, traditional markings and mutilations in girls and boys
  • Depo-Provera (DMPA) for birth control, which increases women’s risk to acquire and to transmit HIV (Hapgood, 2018); 70% of DMPA in Africa was delivered within the framework of development cooperation.
  • Campaigns to circumcise millions of men in Africa (Howe 2011) despite evidence of high risk for surgery in Africa (Weisser, 2008; Biccard, 2018).

Aside from HIV, skin-piercing procedures with unsterile instruments are responsible for almost all of Africa’s heavy burden of hepatitis C virus (HCV) infections. Treatment alone will not solve Africa’s burden of HCV disease. WHO’s strategy to treat HCV will enrich Gilead and some health institutions, but lower HCV incidence will be, at best, modest if “bad medicine” and “drug addiction” are not targeted — eradicated or at least reduced.

What to do to slow HIV and HCV transmission in Africa?

WHO and other international health organizations should urge African governments to:

  • discourage unnecessary injections, surgery, transfusions and other skin piercing procedures;
  • strengthen quality control, including especially reliable sterilization of reused skin-piercing instruments;
  • educate the public about dangers from unsafe and unnecessary healthcare.

A key component of both healthcare quality control and public education about risks is to investigate adverse events – such as suspected nosocomial HIV and HCV infections — and to report findings to the public. Investigations trace and test patients attending hospitals and clinics suspected to be responsible for nosocomial infections. Governments of Russia (1988-89), Romania (from 1989), China, Kazakhstan, Kyrgyzstan, Libya (from 1998), Cambodia (2014-15), and other countries investigated suspected nosocomial infections to find hundreds to thousands of infections (see summaries and references in: Gisselquist 2007; Gisselquist no date).

To date, no government in sub-Saharan Africa has investigated suspected nosocomial HIV infections to see if they are part of an outbreak. This has been a huge mistake.

Links

References

Did dirty healthcare infect a lot of people in KwaZulu-Natal?


For decades, researchers have not been able to explain how so many people in Africa could be getting HIV from sex. At the same time, researchers and public health managers have been trying to avoid and ignore evidence that injections, antenatal care, tattooing, and other skin-piercing blood contacts are responsible for a lot of HIV infections.

Sometimes some evidence slips through. For example, a survey of students in five public high schools in Vulindlela subdistrict in KwaZulu-Natal, South Africa, reported 56 (54% of) 104 HIV-positive girls said they were virgins; and so were 21 (55%) of 38 HIV-positive boys.[1] The study ignored the possibility students got HIV from healthcare; instead the authors suggested women lied about being virgins. Students were doubly harmed: Injury (HIV from healthcare) followed by insult (accusation of sexual misbehavior).

Some new evidence may be harder to sweep under the rug. First some explanation of what this evidence shows. Each HIV is a large molecule made of thousands of parts (smaller molecules). Over time, these parts change little by little. Researchers can take HIV from anyone and “sequence” it to determine its parts. After taking HIV from a lot of people,  they can do a “phylogenetic analysis,” looking for similarities among HIV from different people. Very similar HIV can show one person very likely infected the other. If two HIV are less similar, transmission may have happened a long time ago, or may not have been direct, but rather through others. With phylogenetic analysis, researchers can draw trees (phylogenetic trees) showing the likely connections among a lot of HIV.

Now the new evidence: In March 2018, a team of researchers from South Africa and the UK reported a study that sequenced more than 1,300 HIV collected from adults in mKhanyakude District, KwaZulu-Natal Province, South Africa.[2] They were surprised to find a cluster of 75 very similar HIV. Even more telling, most of the links (transmissions) in this cluster occurred during a matter of months in 2014.

Slide 10 in the presentation by Coltart (click here and scroll down to slide 10) shows the portion of their tree that includes this cluster.[2] Each horizontal line represents HIV from a different person. The short vertical lines that connect the horizontal lines show who seems to have infected whom (either directly or indirectly). The timeline on the bottom shows when transmissions likely occurred.

Most people in this cluster got infected in 2014. Such rapid transmission to so many people is what one would expect from a bloodborne outbreak – maybe from a hospital or clinic reusing bloody instruments. Distressingly, neither the presenter at the March 2018 conference nor anyone who asked questions mentioned nosocomial (healthcare) risks. As far as researchers are concerned, it’s all about sex…blaming the victim.

More than a dozen large HIV outbreaks with 100s or more infected by healthcare have been investigated in Asia, North Africa, Latin America, and Central and East Europe (click on “outbreaks and unexplained cases” in the menu on the right). But nobody has investigated any bloodborne HIV outbreak in Africa. Will someone finally wake up and look at what’s happening in KwaZulu-Natal?

In any case, people living in communities with a lot of HIV in Africa should be careful about blood exposures. Make sure skin-piercing instruments are at least boiled. Be aware: you can’t trust the researchers and public health managers to protect you from HIV during healthcare. They have been denying and ignoring the risk…and blaming HIV-positive people for sexual misbehavior.

References

1. Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmission among students. AIDS Res Hum Retroviruses 2014; 30: 956-965, Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 4 April 2018).

2. Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&&crd_fl=0&ssmsrq=1522772955419&ctms=5000&csmsrq=5001 (accessed 4 April 2018).

New reports of HIV outbreaks from unsafe healthcare in India and Pakistan


The outbreaks

India: On 5 February 2018, newspapers reported a nosocomial HIV outbreak in Unnao after multiple HIV-positive tests at health camps on 24-27 January. Many of the infected reported injections from a quack.[1] As of 10 February, 75 HIV infections have been reported in the outbreak, including at least 6 children; testing continues[2].

Pakistan: On 15 February 2018, the Daily Pakistan reported 22 identified HIV infections in Kot Momin. The article reports speculation that treatments by a quack doctor spread HIV.[3]

Director General of India’s National AIDS Control Organization (NACO) misleads and stigmatizes

After a team from India’s National AIDS Control Organization (NACO) visited Unnao on 7 February, the NACO Director, Sanjeeva Kumar said: “The virus can’t survive in the sun beyond a minute, so while a contaminated syringe may have caused stray infections, it cannot lead to a spurt in HIV cases.”

The Director’s statement is dead wrong and dangerous in three ways:

(a) The virus survives for hours in the open air, even when dry (see references at: https://dontgetstuck.org/introduction-3/prevention-lies-and-abuse/what-is-your-risk/).

(b) The comment ignores investigated outbreaks in Russia, Romania, Libya, etc (see references at: https://dontgetstuck.org/cases-unexpected-hiv-infections/).

(c) The NACO’s Director’s comments stigmatize any resident of Unnao who speaks out to say they have an HIV infection from health care — stigmatizing them with suspicion they are promiscuous. Was it the intent of the Director to stigmatize and thereby silence people who might speak out about HIV from healthcare?

Government of Pakistan promises a thorough investigation

Quote from Urdu Point, 17 February 2018:[5] “Punjab Health Minister Khawaja Imran Nazir has said that emergency steps have been taken to control increasing cases of HIV Aids and Hepatitis in and around Kot Imrana near Kotmomin on the directions of Chief Minister Punjab Muhammad Shehbaz Sharif.”

“During his visit to a medical camp set up at the village for collection of blood samples of the area people, the minister said that thousand of samples had been sent to laboratory so far and the report would be received on Feb 20. He said that after receiving of the reports, the affected people would be provided free-of-cost treatment while a well-equipped laboratory for HIV and Hepatitis would be functional at THQ Kotmomin within two weeks.”

References

1. Unnao HIV cases: chief medical officer got alert in July but didn’t act. NYOOZ, 11 February 2018. Available at: https://www.nyoooz.com/news/lucknow/1031130/unnao-hiv-cases–chief-medical-officer-got-alert-in-july-but-didnt-act/ (accessed 21 February 2018).

2. Williams H. Fake doctor infects 75 Indian patients with HIV. World Report Now, 10 February 2018. Available at: https://www.worldreportnow.com/fake-doctor/6754/ (accessed 21 February 2018).

3. Rehman D. The shocking reason AIDS is spreading in this Pakistani village for last 15 years. Daily Pakistan 15 February 2018. Available at: https://en.dailypakistan.com.pk/pakistan/the-shocking-reason-aids-is-spreading-in-this-pakistani-village-for-last-15-years/ (accessed 21 February 2018).

4. Kaul R. Report on Unnao HIV cases: Migrant population unprotected sex among main causes. Hindustan Times, 18 February 2018. Available at: https://www.hindustantimes.com/india-news/report-on-unnao-hiv-cases-migrant-population-unprotected-sex-among-main-causes/story-Tvi8tsl2qInh51gMrviNPM..html  (accessed 18 February 2018).

5. Shabbir F. Punjab health minister for provision of better health facilities in Kot Momin. Urdu Point, 17 February 2018. Available at: https://www.urdupoint.com/en/health/punjab-health-minister-khawaja-imran-nazir-fo-263040.html (accessed 21 February 2018).

Breaking the silence: asking KfW what it’s doing about HIV from healthcare


In 2011, Grimm and Class[1] urged Germany’s Development Bank (KfW) to pay attention to evidence “an important share of new infections in high prevalence settings occurs through blood exposures in formal and informal healthcare,” and called for “interventions targeted to strengthening the health care system in general and infection control in particular.”

How has KfW responded? Helmut Jager, a medical doctor, initiated an email exchange with KfW to ask just that. He documents the dialogue on his website[2] (for those who can’t read German, here’s a translation tool: https://www.deepl.com/translator).

Questions to KfW on 22 December 2017:

What conclusions did KFW 2012 draw from the analysis of the authors Grimm and Class of 2011?

To your knowledge, have there been epidemiological studies on HIV outbreaks ever since that time…?

What measures does KfW support to prevent iatrogenic and nosocomial infections (especially hepatitis C and HIV)?

Answer by Patrick Rudolph, KfW, Sector Policy Unit Health & Social Protection, on 19 January 2018:

… thank you for your interest in the position and commitment of KfW Entwicklungsbank in the field of infection prevention.

… The key factors for the direction and design of such [HIV] projects are therefore the partner’s sector strategy considerations and the corresponding guidelines of the Federal Government (including the strategy for the control of HIV, hepatitis B and C and other sexually transmitted infections).

We support… a differentiated, demand-oriented and multisectoral approach to HIV prevention depending on the specific micro-epidemiological constellations. This may include measures to prevent both sexual and iatrogenic infections… [I]n South Africa – currently the only country in which the fight against HIV is the focus of German development cooperation in the health sector – the focus is clearly on preventing the sexual transmission of the pathogen…

In response, Dr Jager mailed these additional questions to Dr Rudolph, KfW, on 19 January 2018:

… thank you very much for your reply… Unfortunately, you have not answered my specific questions.

As early as 1990, we had already published that with regard to infections caused by the health care system, the technical equipment of blood banks was not able to solve the quantitatively much bigger problem (unnecessary indications, lack of user hygiene and improper handling of needles and syringes). The consequence of this knowledge should have been investments in the control and prevention of dangerous medical applications. This is evidently not done for the most part…

Are you really sure that…HIV proliferation in South Africa, for example, can only be explained by sexual activity? My doubts intensify among other things a study of 2014 (Kharsany 2014[3]) describing the dynamics of HIV infection of high school students in rural South Africa: 6.8% of girls were infected [including many self-reported virgins]… Where these girls infected themselves with HIV… remained unclear…

As this exchange shows, Dr Jager is challenging those who pay for HIV prevention programs to reconsider their lack of attention to HIV from unsafe healthcare. But Helmut Jager’s website is about a lot more than HIV risks in Africa; I recommend it to anyone with an interest in the history of healthcare, problems in healthcare systems, and future options.

References:

  1. Grimm M, Class D. The fight against HIV/AIDS must be brought into balance. KFW-Development Research: views on development. No 3, 24 June 2011. Available at: https://www.kfw-entwicklungsbank.de/Download-Center/PDF-Dokumente-Development-Research/2011_06_ME_Class-Grimm-The-fight-against-AIDS-must-be-brought-to-balance_E.pdf (accessed 8 February 2018).
  2. Helmut Jager. AIDS in Afrika. Available at: http://www.medizinisches-coaching.net/artikel/medizin/qualitaet_evidenz/aids-in-afrika.html (accessed 8 February 2018).
  3. Karsany ABM, Buthelezi TJ, Frolich JA, et al: HIV infection in high school students in rural South Africa: role of transmission among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 9 February 2018).

 

Hepatitis C eradication and profit


Note: This is a guest blog by Helmut Jäger. Dr Jäger’s website and blog provides more information and thoughtful comments on healthcare issues at: http://www.medizinisches-coaching.net/

Good news: hepatitis C can be cured

Since 2016, the World Health Organization recommends treating hepatitis C infection with sofosbuvir (NS5B-Polymerase-inhibitor)The manufacturer (Gilead) demands an extremely high price, and

“.. the public paid twice: for the pharmaceutical research and for the purchase of the product. The enormous profits flow to the Gilead shareholders.”(Roy BMJ 2016, 354: i3718)

The evidence for the effectiveness of direct-acting antivirals (DAA) for chronic hepatitis C comes from short-term trials. Cochrane is unable to determine the effect of long-term treatment with these drugs:

DAAs may reduce the number of people with detectable virus in their blood, but we do not have sufficient evidence from randomised trials that enables us to understand how SVR (sustained virological response: eradication of hepatitis C virus from the blood) affects long-term clinical outcomes. SVR is still an outcome that needs proper validation in randomised clinical trials. (Cochrane 18.09.2017: http://www.cochrane.org/CD012143/LIVER_direct-acting-antivirals-chronic-hepatitis-c.)

Egypt is particularly affected by hepatitis C. Here the government negotiated special discounts with Gilead, so that relatively cheap treatment will be available. It’s the foundation of just another lucrative business based on a man-made disaster.

tourcure

Tour’n Cure: The profitable medical eradication of a problem that would not exist without medicine.

Bad news: Hepatitis C will still be transmitted by skin piercing procedures

About 2-3% of the world’s population is infected with the hepatitis C virus (HCV); 350,000 of these 130-170 million people die per year. HCV causes liver infections, which are chronic in more than 70% of infected persons. That is, they do not completely cure after an infection. After one or maybe two decades, the damaged liver can fail, or develop cancer. The survival rates are low in the late stages of the disease, even under optimal treatment conditions.

Hepatitis C viruses are very sensitive to environmental influences so they are transmitted almost exclusively through blood or blood products or unclean syringes. Unlike hepatitis B or HIV/AIDS, HCV infections through sexual contacts are rare. Hence, the incidence of HCV is an indicator of a dangerous handling of needles, syringes, other medical instruments or products that lead to a direct blood contact. And new cases of HCV are acquired most likely in health care facilities or by intravenous drug use.

Treatment of disease and prevention of new infections 

The World Health Organization (WHO) announced in 2016 that it wants to “combat” hepatitis C and “exterminate” it by 2030. (WHO 2017: http://www.who.int/mediacentre/factsheets/fs164/en/)

unsafe-needles

Hazardous needles somewhere in Africa (image: Jäger, Kinsahsa 1988)

WHO’s optimism is caused by the availability of sofosbuvir. The drug is said to have cured up to 90% of affected patients in clinical trials, and consequently was added to the WHO list of essential medicines. The pharmaceutical company Gilead faces a huge global market with high profit margins (WIPO 2015): The treatment costs in the US are US$84,000 and in the Netherlands €46,000. The production cost of the drug is estimated not to exceed US$140.(‘T Hoen 2016)

Most people affected by hepatitis C are poor. They now learn through the media that their suffering could be cured, and at the same time that this solution seems to be unavailable to them. Consequently, they will demand the necessary funds for humanitarian reasons from their governments. Gilead expects sofosbuvir will not be manufactured and sold without a license (about 100 times cheaper). The Indian authorities already concluded in 2016 a license agreement with Gilead, which will guarantee high profit rates on the subcontinent.(‘T Hoen 2016)

Attractive medical products and markets increase the risk of the production of counterfeit medicines

In India, the requirement to allow the production of the hepatitis C drug in the “national interest” license-free is not only risky for legal reasons. India already is the world’s leading producer of fake medicines. Counterfeit drugs look exactly like real ones, but contain nothing (in the best case) or poison. About 35% of the malaria drugs in the African market are fake or useless, and they are mostly from India or China (see below: fake drugs). In the case of Egypt, medical institutions tried to open up a lucrative international market (“Tour’n cure”). Therefore, it will not be long until the first fake “sofosbuvir preparations” are offered.

The history of the hepatitis C epidemic in Egypt

The disaster of hepatitis C contamination started in Egypt more than sixty years ago. Efforts to regulate the Nile increased the risk of schistosomiasis infections. These parasites cause numerous health problems, mostly in the pelvic organs, and in rare cases, cancer. The worm larvae swim in stagnant water that has been contaminated by human urine or feces, and they enter the blood system of healthy people by piercing the skin.

The frequency of these worm infections increased rapidly after 1964, when the fast-flowing Nile was tamed by the Aswan Dam. In a relatively short time 10% of the Egyptian population was colonized by the parasite. The Ministry of Health then treated large parts of the population with injections containing antimony potassium tartrate. Until 1980 this toxic compound was considered the only effective remedy for this worm-infection. Today it is no longer used, not even in veterinary medicine.

Many years after the start of the campaign an initially unexplained epidemic of hepatitis C  was noticed in Egypt. It turned out that most of the patients with hepatitis C virus received anti-schistosomiasis injections.

Those initially infected with hepatitis C virus had higher risks to be treated in health care facilities, where the virus was then transmitted to other patients. Today (according to different estimates) 3-10% of the Egyptian population is infected with hepatitis C, and 40,000 patients die per year with the disease. Because many patients are infected, today the risk to acquire hepatitis C infection in Egyptian health facilities, even in optimal hygenic conditions, is significantly higher than in countries where hepatitis C is relatively rare.(Strickland 2006, WHO 2014)

Hepatitis C epidemic in industrialized countries

But Egypt is not an isolated case. Hepatitis C affects mostly the residents of developing and emerging countries. But even in Germany more than half a million HCV infections are recorded.

In England, in 2015 the government had to apologize for the infection of nearly 3,000 people who received infected blood products between 1970 and 1990.(Wise 2015)

In the US hepatitis C is called a “hidden epidemic” because 300,000 people were infected each year a few decades ago.(Ward 2013, Warner 2015, CDC 2015, RKI 2015, Pozzetto 2014)

Syringes and blood products are dangerous if handled improperly or if they are used although they are not necessary

blood

Blood Bank in Kinshasa (Congo, 1990, image: Jäger)

Needles (in particular the worldwide introduction of disposable syringes and their inflationary use) contributed to the spread of viruses like HCV, HIV and others.(Jäger 1990-92) The problem of the HCV epidemic is caused by the health care system and its waste products that fall into the wrong hands. The causes of the infections mostly are: bad medicine or intravenous drug addiction. What happened in Egypt is just another example that sometimes (medical) solutions of seemingly controllable health problems can lead to much larger problems: because sometimes “the things bite back.”(Tenner 1997, Dörner 2003)

Therefore WHO’s strategy to eradicate hepatitis C, based only on treatments, cannot succeed as long as the much of the medical sectors in many poor countries remain dangerous-purely-commercial and in large parts uncontrolled. The WHO campaign certainly will enrich Gilead and some health institutions, but a reduction of the hepatitis C incidence will not take place if “bad medicine” and “drug addiction” are not targeted, preferably eradicated, or at least reduced.

Unnecessary medicine is risky and should be avoided

WHO and other international health organizations should strive to avoid unnecessary therapeutic skin piercing procedures, injections, surgery and transfusions, and (if these sometimes life saving procedures are necessary) establish strict quality control. The commerce of medical tourism and beauty-interventions (botox, piercing, tattoo) should be strictly controlled.

unsafe-injection

Hazardous needles anywhere else in Africa (image: Jäger)

And we should invest in training patients: They should be supported to reduce their demand for health-care-products and to increase their knowledge in order to distinguish “good” and “bad” medicine.

 More

Literature

Bad Medicine in economically weak countries (such as “fake drugs”):

Why things bite back

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 http://home.earthlink.net/~jjpotterat/book.html).

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:http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdf). 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


return to first research page

A wife, husband, and children can be hurt when a gossip — with no evidence — spreads rumors that the wife or husband have lovers.

This situation threatens many HIV-positive married men and women in Africa. HIV prevention programs say most infected adults — including wives and husbands with HIV-negative partners — got HIV from lovers, even if there is no evidence they had lovers, and even if they deny it. Such HIV prevention messages are equivalent to rumors — averring without evidence that people had secret lovers and lied about it.

Researchers have supported such unfounded “rumors.” For example, a UNAIDS-funded study in Zimbabwe followed adults to see who got HIV and what were their risks. After finding and reporting that “[t]hirteen of 67 individuals seroconverting in this study reported no sexual  partners in the inter-survey period..” the authors opined: …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 women who are HIV-positive, what % of  husbands are HIV-negative?

wife+ husband-

Sources: Demographic and Health Surveys and AIDS Information Surveys for each country available at: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence).

Seeing such data and recognizing “women’s low self-reported levels of extramarital sex, a World Bank economist opines: “…I conclude that the sizable fraction of discordant female couples is extremely difficult to explain without extramarital sex among married women.”[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 healthcare professionals (behaving like gossips) who propose his wife lied? It is relevant, as well, that healthcare professionals have a conflict of interest – the alternative to blaming wives for adultery is to acknowledge their HIV may have come from unsafe healthcare.

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: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence).

References

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: http://www.plosmedicine.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pmed.0020037&representation=PDF

2. de Walque D. Sero-discordant couples in five African countries: implications for HIV prevention strategies. Pop Dev Review 2007; 33: 501-523. Abstract available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1728-4457.2007.00182.x (accessed 28 October 2018).

Cambodia


Roka Commune outbreak

In November 2014, a 74-year old man in Roka Commune, Cambodia, tested HIV-positive. He sent his granddaughter and son-in-law for tests. They also tested positive. Alarmed by these unexpected HIV infections, more residents of Roka Commune went for tests; many were HIV-positive.

The next month, December 2014, Cambodia’s Ministry of Health initiated an investigation with collaboration from WHO, the US CDC, UNAIDS, UNICEF, and the Pasteur Institute in Cambodia.[1]

Three papers report results from this investigation.[2,3,4] Results are limited to 242 persons testing HIV-positive through end-February  2015. Comparing HIV-positive residents with neighbors, infected residents had received more injections, infusions, and blood tests. Reports say nothing about specific failures in infection control (e.g., did providers give injections after changing needles but reusing syringes? did providers give infusions with reused plastic tubes and saline bags?). Many persons were co-infected with hepatitis C, which unsafe healthcare had been spreading in the community for years before the HIV outbreak.

Using information from these reports, one of the managers of this website (DG) estimated the transmission efficiency of HIV through contaminated injection equipment at 4.6%-9.2% (this is the risk that an injection administered to an HIV-positive person during the outbreak transmitted HIV to a subsequent patient).[5]

Other information related to the Roka outbreak

In early 2017, a newspaper article reported 292 infections in the outbreak.[6]

As in many other nosocomial HIV outbreaks, children were on the front lines: 22% of cases were in children <14 years old.[2]

Alerted by the investigation, people looked for unexpected infections and unsafe practices elsewhere in Cambodia. A December 2015 BBC article – one year after Roka broke into public view – reports continued and common unsafe practices.[7] 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[8]. 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.

See also these dontgetstuck.org blogs posts

References

1. Eng Sarath. Ministry of Health, Cambodia. 24 December 2014. HIV cases in Sangke district, Battambang. Available at: http://www.cdcmoh.gov.kh/97-hiv-cases-in-sangke-district-battambang

2. 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: http://www.cdc.gov/mmwr/volumes/65/wr/mm6506a2.htm (accessed 28 March 2016).

3. Saphonn V, Fujita M, Samreth S, et al. Cluster of HIV infections associated with unsafe injection practices in a rural village in Cambodia. J Acquir Immune Defic Syndr 2017; 75: 285-e86. Available at: https://journals.lww.com/jaids/Citation/2017/07010/Cluster_of_HIV_Infections_Associated_With_Unsafe.19.aspx (accessed 12 February 2018).

4. Rouet F, Nouhin J, Zheng D-P, et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin Infect Dis 2017; epub ahead of print. Available at: https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1071/4689456?redirectedFrom=PDF (accessed 12 February 2018).

5. Gisselquist D. HIV transmission efficiency through contaminated injections in Roka, Cambodia. biorxiv 2017. Available at: https://www.biorxiv.org/content/biorxiv/early/2017/05/15/136135.full.pdf (accessed 12 February 2018).

6. Millar P. How the residents of Cambodia’s “HIV village” are coping more than two years on. Southeast Asia Globe, 15 March 2017. Available at: http://sea-globe.com/how-the-residents-of-cambodias-hiv-village-are-coping-more-than-two-years-on/ (accessed 14 August 2017.

7. John Murphy. BBC, 17 December 2015. A country in love with injections and drips.
Available at: http://www.bbc.com/news/magazine-35111566

8. Aun Pheap, George Wright. Doctor denies spreading HIV in latest outbreak. Cambodia Daily News 22 February 2016. Available at: https://www.cambodiadaily.com/news/doctor-denies-spreading-hiv-in-latest-outbreak-108791/ (accessed 28 March 2016).

See also:

Kehumile Mazibuko. News Tonight Africa, 4 December 2015. Cambodia: unlicensed medical practitioner sentenced for infecting more than 100 people with HIV. Available at: http://newstonight.co.za/content/cambodia-unlicensed-medical-practitioner-sentenced-infecting-more-100-people-hiv

Khy Sovuthy, Anthony Jensen. Cambodia Daily, 8 December 2015. In HIV case, key evidence trails behind guilty verdict. Available at: https://www.cambodiadaily.com/news/in-hiv-case-key-evidence-trails-behind-guilty-verdict-102320/