Don't Get Stuck With HIV

Protect yourself from HIV during healthcare and cosmetic services

Hundreds of children in Pakistan infected by HIV from health care; government investigates to protect children


Beginning end-April 2019, government of Pakistan has been investigating an outbreak of HIV from unsafe health care in Ratodero county. As part of the investigation, government set up camps to test people for HIV. As of 23 May, tests on 20,800 people in Ratodero found >608 to be infected, including >500 children.[1] Almost all HIV-infected children had HIV-negative mothers. 

According to a recent report[2]: “Adviser to the Prime Minister for Health Dr. Zafar Mirza has said that outbreak of HIV in Ratodero has not only shaken the country but entire world adding when he was in Geneva he was also asked about surfacing of HIV… He said root cause of large number of children must be detected… He said federal government along with UNICEF, WHO, UNAID, Aga Khan, Aga Khan University Hospital and other organizations is cooperating with the Sindh government in this connection and they will continue to coordinate till root cause is detected, he added.”

In sub-Saharan Africa, children get HIV from unsafe healthcare, but no government has investigated to protect them

Lots of HIV-positive children with HIV-negative mothers are reported in Africa, but unlike Pakistan, no government has investigated. Nor have WHO or UNAIDS advocated any investigation. Here are some of the many reports of HIV-positive children in Africa with HIV-negative mothers:

* Mozambique, 2015: A random sample national survey found 30 HIV-positive children aged 6-23 months; 10 (33%) of the 30 children had mothers who were HIV-negative.[3]

* Uganda, 2011: A random sample national survey tested adults and children aged 0-5 years for HIV. Based on reports from this survey,[4] an estimated 17% (12 of 70) HIV positive children had mothers who tested HIV-negative (click on “outbreaks and unexpected infections” and then “Uganda” country page).

* Mozambique, 2009: A random sample national survey in 2009 tested children as well as adults for HIV. The study found 63 HIV-positive children aged 0-11 years old, of which 18 (29%) had mothers who tested HIV-negative.[5,6]

* Swaziland, 2006-7: A random sample national survey tested 1,665 mother-child pairs with children aged 2-12 years. Fifty children were infected; 11 (22%) of their mothers tested HIV-negative.[7,8]

WHO’s double standard

WHO’s double standard goes back decades. For example, during 1990-93, WHO’s Global Programme on AIDS coordinated studies in four African countries – Kigali, Rwanda; Kampala, Uganda; Dar es Salaam, Tanzania; and Lusaka, Zambia – to test inpatient children and their mothers for HIV infection. Combining data from the four cities, 61 (1.1 percent) of 5,593 children aged 6-59 months were HIV-positive with HIV-negative mothers.[9] Only three children had been transfused. Although these infections suggested a lot of HIV transmission through unsafe healthcare, WHO, incredibly concluded ‘the risk of…patient-to-patient transmission of HIV among children in health care settings is low.’[10]

At least WHO in 2019 is acting to protect children in Pakistan from getting HIV from unsafe healthcare. Will this ongoing investigation lead WHO to change its long-standing policy of neglect in Africa?

References

1. Masood T. Situationer: dealing with HIV outbreak among children. Dawn 23 May 2019. Available at: https://www.dawn.com/news/1483999 (accessed 24 May 2019).

2. Dawoodpoto J. “HIV in Ratodero has not only shaken the country but entire world.“ Daily Times 24 May 2019. Available at: https://dailytimes.com.pk/399789/hiv-in-ratodero-has-not-only-shaken-the-country-but-entire-world/ (accessed 24 May 2019).

3. page 231 in: Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), e ICF, 2015. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. Rockville, Maryland: ICF, 2018. Available at: https://dhsprogram.com/pubs/pdf/AIS12/AIS12.pdf

4. Table 8.13 in: Uganda Ministry of Health, and ICF International. Uganda AIDS Indicator Survey (UAIS) 2011. Calverton: ICF International, 2012. Available at: https://dhsprogram.com/publications/publication-AIS10-AIS-Final-Reports.cfm(accessed 6 December 2018).

5. pp. 177-181 in: INS, INE, and ICF Macro. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. Calverton, Maryland: ICF Macro, 2010. Available at: http://measuredhs.com/pubs/pdf/AIS8/AIS8.pdf (accessed 19 January 2012).

6. Brewer D. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. Webmedcentral 2011, Article ID WMC002206. Available at: http://www.webmedcentral.com/article_view/2206(accessed 19 January 2012).

7. CSO, eSwatini, and Macro Int. Swaziland Demographic and Health Survey 2006-07. Mbabane, Swaziland: CSO and Macro International, 2008. Available at:  https://dhsprogram.com/pubs/pdf/FR202/FR202.pdf (accessed 8 November 2018).

8. Okinyi M, Brewer DD, Potterat JJ. Horizontally acquired HIV infection in Kenyan and Swazi children. Int J STD AIDS 2009; 20: 852-857. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19948900(accessed 27 October 2018); article available at: http://www.interscientific.net/IJSA2009Okinyi.html (accessed 15 October 2018).

9. Hitimana D, Luo-Mutti C, Madraa B, et al. ‘A multicentre matched case control study of possible nosocomial HIV-1 transmission in infants and children in developing countries’, 9thInt Conf AIDS, Berlin 6-11 June 1993. Abstract no. WS-C13-2.

10. Global Programme on AIDS. 1992-1993 Progress Report, Global Programme on AIDS. Geneva: WHO, 1993. p. 85.

Antimicrobial Resistance and PrEP: Medical Disasters


Here are two antimicrobial resistance (AMR) scenarios, one rapidly spiraling out of control, and the other (arguably) incipient:

The AMR scenario that is spiraling out of control is described in an article in The New York Times. The development of AMR is blamed on overuse and misuse of cheap antibiotics, usually without prescription. Ever-increasing use and misuse of antibiotics results in ever-increasing development of resistant strains of pathogens.

The NYT article describes the appalling conditions that an estimated one billion people live in; slums where waterborne, foodborne and airborne pathogens thrive. Unable to escape the risks, people try to treat the symptoms with antibiotics, inevitably leading to resistance to most or all available treatments.

The scenario described is a loop: widespread disease leads to overuse of antimicrobials; this leads to development of resistance; people with resistant conditions, if they survive, are taken to healthcare facilities, which also overuse antimicrobials, amplifying resistance and transmission of resistant strains; this loops back to the slum, resulting in an even higher disease burden, and greater levels of resistance.

The loop could be broken by: 1) improving the environment, including water, sanitation, habitation, food, etc and 2) improving conditions in healthcare facilities, infection control, safety, hygiene, etc. This will reduce antimicrobial use and, therefore, resistance.

The approach suggested by the Global AMR R&D Hub, on the other hand, risks speeding up the loop leading to AMR. They aim to “tackle the threat of resistant pathogens” by developing “new antibiotics and treatments against infections.” Producing antimicrobials of ever-increasing power, without addressing 1 and 2, above, only continues the cycle of ever-increasing resistance.

The other scenario is described on websites such as iwantprepnow.co.uk (and prepster.info and others). They advise on the use of PrEP (pre-exposure prophylaxis), antiretrovirals taken by HIV negative people to reduce the risk of HIV infection. For example, if “you have sex in a variety of situations where condoms are not easily used or not always used”, PrEP, if properly used, can reduce risk of infection with HIV by more than 90%.

There are (at least) two problems with this. Firstly, overuse or incorrect use of antiretrovirals can give rise to a resistant strain of HIV developing in an infected person, and that resistant strain can also be transmitted to others.

Secondly, the advice from iwantprepnow.co.uk (and other similar sites, such as PrEPster.info) is aimed at people who frequently have sex without protection from other sexually transmitted infections (STIs). Exposing yourself repeatedly to infection with STIs increases the development of resistant strains of, for example, gonorrhea, shigella and Mycoplasma genitalium.

Use of PrEP without condoms also increases transmission of hepatitis C virus: “Incidence of acute hepatitis C virus (HCV) among men who have sex with men who use PrEP in Lyon increased tenfold between 2016 and 2017”. HCV has doubled among HIV positive people.

The Center for Strategic and International Studies spectacularly fail to notice the positive feedback mechanism, whereby improper use of PrEP could increase transmission of STIs and the development of resistance in countries where HIV prevalence is highest, sub-Saharan African countries:

“In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin.” The same article even acknowledges that “High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition”, without noticing how PrEP will increase STIs and resistance!

According to The WHO, health is a “State of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” In the two AMR scenarios described above, producing stronger antimicrobials and PrEP are examples of medicalization of health, viewing it as merely the absence of disease or infirmity. These kinds of medicalization will radically increase AMR.

Cherie Blair and ‘Rape in Africa’ Stereotypes


Cherie Blair was accused of perpetuating and reinforcing stereotypes and usurping African voices with her comment that “most African ladies’ first sexual experience is rape”. The English Guardian and NPR both weigh in, with a number of reasons why Blair’s remarks were met with outrage.

Critics of Blair are not wrong in calling her out on these comments. But they don’t go far enough. Yes, Blair should have acknowledged, for example, that rape and gender based violence are faced by women everywhere, not just in African countries. But Blair is only repeating stereotypes she would find throughout the mainstream media, and in a lot of specialized published sources.

Blair is far from being alone in perpetuating and reinforcing stereotypes, such as those of the ‘promiscuous African’, ‘the violent African male’, ‘the widespread exchange of sex for money’, ‘the disempowered African female’, etc. Most of these stereotypes are a lot older than Blair, and date back to colonial times, at least.

Nor have the long-held stereotypes mellowed with age. The bulk of HIV programming (and spending) is based on the very assumption that “sexual transmission [is] the major mode of spread of HIV-1 in Africa”, with some estimates suggesting that sex accounts for 80-90% of all transmissions in high prevalence countries (which are all in sub-Saharan Africa).

On the subject of rape, the Center for Strategic and International Studies (CSIS) claims that: “Girls and women [in South Africa] also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.”

CSIS was commenting on the fact that in some parts of South Africa, 60% of women are HIV positive. Many new infections are among girls 15-24 years old. However, the entire CSIS article assumes, without ever arguing for it, that all HIV transmission is sexual. This assumption may suggest that stereotypes such as those above are based on empirical findings, rather than being rank prejudice.

Far from being based on research, stereotypes about ‘African’ sexual behavior are flatly contradicted by vast quantities of data collected by Demographic and Health Surveys, every five years, about sexual behavior in African countries. Just select any sub-Saharan country; rates of ‘unsafe’ sexual behavior are low, and there is little or no correlation with HIV prevalence.

Cherie Blair is unlikely to have come across views that diverge from the mainstream prejudices about HIV in SSA, and that challenge those prejudices. But many of those challenges can be found, for example, in a paper by John Potterat, and in the bibliography for that paper. One of the main suspects in high rates of HIV transmission is unsafe healthcare; others are unsafe cosmetic and traditional practices.

If Blair would like to reconsider the sort of stereotypes about sexual behavior and violence also expressed in the CSIS article, this is a good time to do so. Those outraged by her comments about ‘Africans’ and their alleged sexual behavior may wish to avail of the same research. Otherwise they all risk reinforcing and perpetuating stereotypes.

Ebola: A Strategy of Misinformation?


In an article in The New England Journal of Medicine entitled ‘An Epidemic of Suspicion — Ebola and Violence in the DRC’ Vinh-Kim Nguyen writes about violent attacks on Ebola treatment units and other health facilities. Nguyen argues that: “Epidemics thrive on fear — when they are frightened, patients flee hospitals, sick people stay away to begin with, and affected communities distrust groups trying to respond to the epidemic.”

But there’s an important sense in which the opposite may be true. When people fear something that has proven dangerous in the past, avoiding that something may be the only rational response, the only way to avoid the danger. After all, several well-documented epidemics have been shown to thrive on unsafe healthcare. Examples are Ebola Virus Disease (EVD), hepatitis C (HCV), extensively drug resistant tuberculosis (XDR TB) and MRSA (Methicillin-resistant Staphylococcus aureus).

The second ever outbreak of EBV, which occurred in Yambuku (in Zaire) in 1976, was a result of unsafe healthcare: “Peter Piot…concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes.”

WHO has recently announced that “The outbreak [of EBD] in Katwa and Butembo health zones [in DRC] is partly being driven by nosocomial [=originating in a hospital] transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission.”

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people…. [T]he wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs. A significant healthcare associated outbreak occurred in Egypt in the 1970s.

Associated with poor infection control in health facilities, one of the first outbreaks of XDR-TB was discovered in Tugela Ferry Hospital, KZN, South Africa, in 2005. And a significant proportion of healthcare associated infections are resistant to methicillin (ie, MRSA).

Nguyen goes on: “In areas where the epidemic response has not involved security forces…people ask to be vaccinated.”

But rolling out vaccinations in environments where infection control is inadequate (for example, healthcare facilities) might increase the risk of viral strains developing resistance (for example, among healthcare practitioners). Going to a healthcare facility during an outbreak of Ebola may be the worst thing a person can do. When people didn’t go to health facilities during earlier outbreaks, case numbers were limited, and the outbreak didn’t last long.

Nguyen has also highlighted the importance of trust, and the consequences of mistrust of authority, experts and science. But if people are right to question the safety of healthcare facilities, as it would appear from above considerations, how can the trust of people at risk of exposure to ebola and other pathogens be regained?

As long as continued Ebola transmission is blamed on what is depicted as an irrational fear of healthcare and vaccinations, people will stay away from healthcare. Because their fear is far from irrational, it is supported by scholarly research, expert opinion and even communications from the WHO. XDR TB, MRSA, HCV and other outbreaks have been shown to be healthcare associated outbreaks. Healthcare facilities also contribute the lion’s share to anti-microbial resistance (AMR).

Modern healthcare facilities are potentially dangerous places. If patients were informed about the dangers, they would know better how to avoid them, and healthcare facilities would be compelled to address those dangers. Some of the earliest EBV outbreaks occurred when people came together around healthcare facilities, and died out when healthcare facilities closed, often because healthcare staff had been wiped out by Ebola.

Trust in healthcare in developing countries may be regained, slowly, if people are adequately informed about the greatest risks they face, such as poor infection control, lack of hygiene, AMR, etc. Trust will not be regained by dreaming up new misinformation, nor by reinforcing old misinformation.

Addressing a running sore: HIV in South Africa


Introduction

South Africa, where doctors achieved the first human heart transplant and one of the wealthiest countries in Africa, has a terrible HIV epidemic. In 2015, an estimated 30.8% of pregnant women were HIV-positive at their first antenatal visit, with more pregnant women infected in parts of the country: for example, 44.5% in KwaZulu-Natal province and 48.4% in Zululand district of that province.[1] Even more adults were infected in some age cohorts and regions: for example, in a 2014 survey of a study population in uMungundlovu district, KwaZulu-Natal, more than 66% of women aged 30-39 years were HIV-positive as were 59.6% of men aged 40-44 years.[2] Although South Africa has only 0.75% of the world’s population, a 2017 national survey estimated 7.9 million South Africans infected,[3] more than a fifth of the world’s total HIV infections.[4]

The South African government is doing a lot of what is required to respond to this epidemic with one glaring exception: the government has not investigated any unexpected and unexplained infections (i.e., not from sex, mother-to-child, or injection drug use) to find and stop blood-borne HIV transmission during health care and cosmetic services.

Doing things right: 90-90-90

In 2014, UNAIDS launched the 90-90-90 initiative, setting targets for testing and treatment to be achieved by 2020: 90% of people with HIV know they are infected, 90% who know are on antiretroviral therapy (ART), and 90% on ART have suppressed viral loads.[5]

Government of South Africa has made encouraging progress towards 90-90-90 targets. In a 2017 national survey, 84.9% of HIV-positive adults aged 15-64 years knew they were infected, 70.6% of those who knew were on ART, and 89.5% of people taking ART were virally suppressed. Putting these numbers together, 54% of HIV-positive adults were virally suppressed (54% = 84.9% x 70.6% x 89.5%).[6] The 90-90-90 targets are intended not only to reduce AIDS sickness and deaths but also to reduce HIV transmission. People with suppressed viral loads are not likely to transmit sexually because they have so little virus in semen or vaginal fluids.

Government of South Africa has also done well with prevention of mother-to-child transmission. As of 2017, more than 95% of pregnant women were tested for HIV and those found infected were given ART both to protect them and to prevent HIV transmission to their babies.[4] In 2016-17, less than 1% of HIV-positive mothers transmitted HIV to their babies before and during birth.[7]

Even before the 90-90-90 initiative, government of South Africa in 2010 began an HIV testing campaign, testing 13.3 million people over 18 months, finding 2 million with HIV, and putting 400,000 on treatment.[8] Also in 2010, government told providers to offer an HIV test to anyone seeking health care at a public facility.[9] To make testing easier, government in 2016 approved sale of self-testing kits through private pharmacies and other outlets.[10] These policies and programs support efforts to reach the testing target for 2020 – that 90% of people who are infected know it. More testing contributes to prevention by making it easier for people to know if their (potential) sex partner is HIV-positive, so they know to use condoms or otherwise protect themselves.

Doing things wrong: not investigating unexpected infections

With more testing, treatment, and other factors, the annual number of new HIV infections in South Africa fell 40% from 386,000 in 2010 to 231,000 in 2017.[3] Even so, South Africa’s HIV/AIDS disaster is reaching the next generation: in 2017 young women aged 15-24 years were getting HIV at the rate of 1.5% per year.[3]

The terrible scale of South Africa’s HIV epidemic is due in part to government not doing what it could to protect people. Over the years, public media and medical journals have recognized and reported unexpected HIV infections in South Africa. Nevertheless, as of early 2019, government has not investigated any unexpected infection by identifying suspected source facilities and then tracing and testing others treated at those facilities. For example, beginning in 1999, a group of doctors in Cape Town from time to time asked about and identified possible health care risks for more than 20 HIV-positive children with HIV-negative mothers.[11,12] But government did not subsequently trace and test others treated at suspected source facilities. Without tracing and testing to find others infected at the same facilities it is not possible to determine the extent of any outbreak or to find and fix the specific lapses in standard precautions responsible; and the public remains at risk.

Government of South Africa’s response to unexpected infections contrasts sharply with responses by governments outside sub-Saharan Africa. For example, in 1988 doctors in Elista, Russia (part of the USSR at the time), found and reported unexpected HIV infections in a hospitalized baby with an HIV-negative mother and a blood donor with no sexual risk. Government investigated, testing thousands, tracing transmission from one child directly and indirectly to 265 children in 13 hospitals, and ending the outbreak by August 1989.[13,14] From 1989 through 2014, nine other governments (Cambodia, China, India, Kazakhstan, Kyrgyzstan, Libya, Mexico, Romania, and Uzbekistan) investigated unexpected infections to uncover nosocomial (through health care) HIV outbreaks with more than 100 to more than 55,000 infections [15-17]). Many other governments have investigated unexpected infections to find smaller outbreaks.[16]

A lot of evidence suggests HIV transmission through skin-piercing procedures in health care, and possibly also during cosmetic services, have been and remain common in South Africa. Following paragraphs summarize selected evidence from later to earlier reports.

Incidence in children aged 2-14 years: The fifth South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2017, reported children aged 2-14 years acquired new HIV infections at the rate of 0.13% per year.[6]

Higher HIV prevalence in Black Africans than in other groups: The same 2017 national survey reported much higher HIV prevalence in Black Africans of all ages (16.6%) than in Whites (1.1%), Coloured (5.3%), or Indian/Asians (0.8%).[6] The survey gives no explanation for these differences in terms of sexual behavior. Male circumcision is not a factor: as of 2012, it was more common among Black African adults (52.4%) compared to Whites (23.3%), Coloured (26.4%), or Indian/Asians (33.5%).[18] There is, however, a big difference in where people get health care: in the second national HIV survey in 2005, 80% of Whites reported they usually get health care from private providers, while 80% of Black Africans reported they got most health care from public services.[19]

Unexplained infections in high school women: A 2011-2017 study in Mpumalanga province tested 2,533 high school women aged 13-20 years; 81 were HIV-positive, including 38 who reported never having vaginal or anal sex.[20] The study then followed and retested the women for 1-6 years during which 190 got HIV, including 44 who reported no lifetime sex.[21] At annual surveys during the first three years of follow-up an average of only 9% of women reported any sex without a condom in the previous three months[22]; and from what women reported about partners’ ages (less than 9% were aged over 24 years) less than 10% were HIV-positive.[22,23] Even if all women reporting unprotected sex in the previous three months had unprotected sex 104 times per year (or twice per week; an intended overestimate, considering most were in school), one could expect to see only 0.1% of women get HIV from sex each year, far less than observed incidence of 1.8% per year[22] (0.1% = 9% of women reporting unprotected sex in the previous three months x 104 sex acts per year x 10% of partners are HIV-positive x transmission efficiency of 1 per 1,000 coital acts; the next paragraph references this estimated transmission efficiency)

(This paper estimates transmission efficiencies of HIV through unprotected vaginal sex at 1 per 1,000 coital acts or 10% per year from an infected spouse based on the following references. The United States Centers for Disease Control and Prevention estimates transmission per unprotected coital act at 0.8 per 1,000 from men to women and 0.4 per 1,000 from women to men[24]. A widely cited estimate from a study in Uganda is 1.2 per 1,000 coital acts (with some condom use, which had no impact on estimated transmission efficiency).[25] Six studies in Africa followed discordant couples in which most partners were not aware of their infections or risks and/or did not use condoms; from these six studies both the mean and average rates of HIV incidence in initially HIV-negative partners were less than 10% per year.[26-31] Here and elsewhere I report rates of HIV incidence as percentages per year, a statistic more familiar for non-technical readers than the technical term, infections per 100 person-years.)

HIV-positive virgin men and women: In a 2014-15 survey among adults aged 15-49 years in uMgungundlovu district, KwaZulu-Natal, 11.2% of (self-reported) virgin women were HIV-positive as were 9.0% of virgin men.[2]

Higher incidence in young women than can be explained by sex: Repeated surveys of a study population in mKhanyakude district, KwaZulu-Natal, reported young women aged 15-24 years acquired new HIV infections at the rate of 5.9% per year (486 infections in 8,211 person-years) during 2011-15.[32] Such high incidence is difficult to reconcile with women’s limited sexual exposures to HIV, suggesting most infections come from risks other than sex. In the 2015 survey, 34% (847/2,467) of young women reported at least one coital act without condoms in the previous year,[32] and HIV prevalence was 10% among men who reported sex with a young woman in the past year.[33] Assuming women who reported unprotected sex in the past year averaged 104 unprotected coital acts per year (an intended over-estimate) and a transmission efficiency of 1 per 1,000 coital acts, sex explains incidence of only 0.4% per year, far less than the observed rate of 5.9% per year (0.4% = 34% of women with any unprotected sex in the past year x 104 coital acts per year x 10% of partners were HIV-positive x 0.001 transmissions per unprotected coital act[24,25]).

Cluster of 63 recent and linked infections: The African Health Research Institute found a cluster of 63 very similar HIV (similar sequences of amino acids) in blood collected during 2011-14 from 1,376 adults in a study population in uMkhanyakude district, KwaZulu-Natal. The Institute estimated HIV from one (unidentified) person in mid-2013 was somehow transmitted directly and indirectly over 18 months to 63 men and women.[34] Such fast transmission does not seem possible through sex, with transmission through vaginal sex requiring on average circa 1,000 coital acts; even for receptive anal sex an estimated average of 70 events are required for each transmission.[24] However, such rapid transmission is seen in nosocomial outbreaks; compare, for example, the phylogenetic tree of HIV genetic sequences from an outbreak in Cambodia[35] with the cluster of 63 HIV sequences from KwaZulu-Natal (slide 10 in [34]).

Unexplained infections in pregnant women: Four studies reported numbers of new HIV infections and rates of HIV incidence ranging from 10.7%-11.2% per year (or data to calculate these statistics[36]) in pregnant women during 2002-12. Women would not get HIV through sex at such rates unless all or almost all of their partners were infected. But during those years, less than 15% of adult men in South Africa were HIV-positive[4]; and many HIV-positive married men were married to women who were already infected.[37] The four studies are as follows: Wand and colleagues followed pregnant women in Durban during 2002-5, reporting data to calculate 81 incident infections in pregnant women and incidence of 10% per year[38]; Moodley and colleagues followed pregnant women in Mpumulanga, Eastern Cape, and Free State during 2006-7, observing 72 incident infections and incidence of 10.7% per year[39]; Kharsany and colleagues followed pregnant women in KwaZulu-Natal during 2007-8, observing four incident infections and calculating incidence of 11.2% per year[40]; and Dinh and colleagues reported 212 incident infections in a national sample of pregnant women and data to calculate incidence at 11% per year.[41]

HIV in high school virgin boys and girls: A 2012 survey of students in grades 8-12, averaging 15.8 years old, in KwaZulu-Natal reported 21 (55%) of 38 HIV-positive boys said they were virgins as did 56 (54%) of HIV-positive girls.[42]

HIV incidence in adults with no reported sex risks: The South Africa HIV Prevalence, Incidence, Behaviour and Communication Survey, 2005 (the second such national survey) reported HIV incidence of 1.5% per year in self-reported virgin adults, 2.4% per year in non-virgin adults who reported no sex in the previous year, and a similar 2.4% per year in adults who said they had been sexually active in the previous year.[43]

South Africa’s early epidemic doubles in 9-14 months: At the beginning of the HIV epidemic among Black South Africans in the late 1980s, the number of HIV-positive people doubled in about nine months[44]. During 1990-94, the doubling time for HIV prevalence in pregnant women throughout South Africa averaged 14 months (from 0.7% in 1990 to 7.6% in 1994).[45] The speed of transmission required for such rapid epidemic expansion is much faster can be explained by estimated rates of sexual transmission (1 per 1,000 coital acts or 10% per year between discordant couples[24-31]).

Fixing South Africa’s incomplete HIV prevention program: investigating unexplained infections

South Africa’s promotion of testing and treatment to reach 90-90-90 targets can be expected to slash sexual transmission. As targets are reached, more than 70% (~90% x 90% x 90%) of those infected will have suppressed viral loads and very little risk to transmit to a sexual partner. And with more testing, more people will know if partners are infected, so they will know to be careful.

But 90-90-90 may have less limited impact on blood-borne transmission. Based on outbreak investigations in other countries, blood-borne infections are often found in bunches. For example, HIV went from one in-patient baby to 265 children in 16 months in Russia,[14] from one to 418 infections in 3-4 years in Libya,[46] and from two to more than 200 infections in several years in Cambodia.[35] Large outbreaks characteristically come from facilities giving repeat treatments, where some people infected earlier get another procedure within weeks to month when they have primary infections and high viral loads, making their blood more dangerous and contributing to later transmissions.

The frequent bunching of blood-borne infections from specific facilities means that any identified unexpected HIV infection should be considered – until proven otherwise – to be one of many in an outbreak. When onward transmission occurs within several months, routine testing is not likely to find people with new blood-borne infections before they infect others through the outbreak. Moreover, even if someone tests HIV-positive with a very early infection, if the only risk anyone thinks about is sex, knowing he or she is infected would have no impact on their getting more skin-piercing procedures at the facility that is the source of the outbreak.

Educating health care workers – a continuing effort – has not stopped unexpected infections. Without outbreak investigations, no one knows the specific skin-piercing procedures and facilities responsible for unexpected infections, so there is no way to know where and how to focus efforts to repair dangerous procedures. Investigations in other countries have implicated a long list of health care procedures, including intra-muscular and intravenous injections, flushing intravenous lines, taking medicine from multi-dose vials, dental care, blood tests, blood and plasma donation, and others. Skin-piercing cosmetic procedures, such as tattooing, shaving, and manicures may also be involved.

Getting from no to yes: Officials in the government of South Africa have for decades consistently decided not to investigate unexpected infections. Increasing public awareness of unexpected infections could create public pressure for investigations. Libya and Cambodia provide examples of public pressure successfully pushing governments to investigate.

  • In Libya in August 1998, a magazine reported HIV infections in children traced to the El Fatah Hospital, Benghazi. The government’s initial response was to close the magazine. But parents did not take “no” for an answer. In November 1998 “a group of desperate fathers interrupted a medical conference Ghadafi was attending in Benghazi and appealed to him for help.”[47] Gaddafi ordered treatment for infected children and an investigation that offered HIV tests to all children treated at El Fatah Hospital in the previous year. The investigation found 418 children with HIV from healthcare.
  • In Roka, Cambodia, in November 2014, a 74-year-old man tested HIV-positive. Surprised, he sent his son-in-law and granddaughter for tests; both were infected. More villagers, alerted and worried, went for tests; many found they were infected. Acting on this information, government began an investigation in mid-December. The investigation reported 242 infections, attributing most if not all to skin-piercing procedures from a local private health care provider.[48,49]

With South Africa pursuing 90-90-90 targets, more people are getting tested. In the 2017 national HIV survey, 75.2% said they had ever been tested for HIV, and 66.8% had been tested within the past 12 months.[3] For many South Africans, an HIV-positive test comes as a surprise. In the previous 2012 survey 80% of adults considered themselves at low risk for HIV, giving reasons such as: “I use condoms”; “I abstain from sex”; “I am faithful to my partner.” But many self-assessed low risk adults were infected, accounting for 56% of adult HIV infections (calculated from data in Table 3.56 in [18]). As testing expands, more people are finding themselves with unexpected infections.

What happens next may well depend on whether people who have unexpected infections are able to get a respectful hearing from counselors, the media, churches, lawyers, support groups, non-government organizations, etc. To date, too few of those who manage or participate in public dialogue about HIV have been willing to believe people who report unexpected infections and to push government to mount the proper response to protect public health, i.e., to investigate, to look for outbreaks.

Making investigations work for public health: From a public health point of view, the priority for investigations is to determine the extent of the problem (to find all who were infected in each investigated outbreak) and to identify specific procedural lapses and facilities responsible. What might be ideal under such circumstances is for government to legislate to allow no-fault investigations along the lines of the post-apartheid Truth and Reconciliation Commission.

Attempting to punish or to collect compensation can create situations of conflict in which people who know what happened are motivated not to tell, investigators are pressured not to look, and blame and punishment fall on scapegoats. Open and thorough investigations educate and alert everyone – health care staff, cosmetic service providers, and the public – to be more aware of blood-borne risks. Punishing past mistakes is not necessary to improve health care safety; many health care staff will no doubt be mortified to learn that what they thought was safe may have infected patients. As for compensation, considering decades of inaction and inattention, it is not easy to identify anyone other than the government which both shares responsibility and has resources commensurate with whatever the problem might be. In any case, those who have been harmed already have free treatment.

Public trust in healthcare safety: Although officials have not explained why they have not investigated unexpected HIV infections, one reason may have been to maintain public trust in health care safety. Outbreak investigations that ask former patients at specific facilities to come for HIV tests challenge that trust by making the public aware of possible mistakes. But that is only a short term view of the matter. Acknowledging, investigating, and fixing problems builds trust in the long term.

Conclusion

No one has identified differences in sexual behavior that could explain much higher HIV prevalence in South Africa than in all non-African countries as well as in all but a few regional countries in Africa. One possible explanation is that lapses in health care safety have been driving South Africa’s epidemic. If that is so, then investigations of unexpected infections could lead to a dramatic drop in HIV transmission.

But even if blood-borne risks make only a limited contribution to South Africa’s epidemic, investigations protect public health. According to the World Medical Association’s Declaration of Lisbon on the Rights of the Patient, health care managers and providers have a responsibility to give patients “medical care of good quality” and “health education that will assist him/her in making informed choices about personal health and about the available health services.”[51] Without outbreak investigations, this is not possible.

Similarly, even if blood-borne risks make only a limited contribution to South Africa’s epidemic, investigations that recognize blood-borne transmission at any level undermine the stigmatizing belief that an HIV infection is a sign of sexual behavior.

References

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22. Pettifor A, MacPhail C, Hughes JP, et al. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial. Lancet Glob Health 2016; 4: e978-e988. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626439/ (accessed 18 December 2018).

23. Gomez-Olive FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, et al. Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care 2013; 29: 1122-1128. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778517/ (accessed 15 December 2018).

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25. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: 1149-1153. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11323041 (accessed 12 December 2018).

26. Hugonnet S, Mosha F, Todd J, et al. Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr 2002; 30: 73-80. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/12048366 (accessed7 February 2019).

27. Senkoro KP, Boerma JT, Klokke AH, et al. HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991 through 1996. J Acquir Immune Defic Syndr 2000; 23: 194-202. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/10737435 (accessed 7 February 2019).

28. Wawer MJ, Sewankambo NK, Berkley S, et al. Incidence of HIV-1 infection in a rural region of Uganda. BMJ 1994; 308: 171-3. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542521/ (accessed 7 February 2019).

29. Serwadda D, Gray RH, Wawer MJ, et al. The social dynamics of HIV transmission as reflected through discordant couples in rural Uganda. AIDS 1995; 9: 745-50. Available at: https://www.ncbi.nlm.nih.gov/pubmed/7546420 (accessed 7 February 2019).

30. Carpenter LM, Kamali A, Ruberantwari A, Malamba SS, Whitworth JAG. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999; 13: 1083-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10397539 (accessed 7 February 2019).

31. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342: 921–9. Available at: https://www.nejm.org/doi/10.1056/NEJM200003303421303?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov (accessed 28 February 2019).

32. Chimbindi N, Mthiyane N, Birdthistle I, et al. Persistently high incidence of HIV and poor uptake in adolescent girls and young women in rural KwaZulu-Natal, South Africa prior to DREAMS. PLoS ONE 6 October 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30325932 (accessed 21 December 2018).

33. Doyle AM, Flowy S, Baisley K, et al. Who are the male sexual partners of adolescent girls and young women? Comparative analysis of population data in three settings prior to DREAMS roll-out. PLoS ONE, 28 September 2018. Available at:  https://www.ncbi.nlm.nih.gov/pubmed/30265667 (accessed 21 December 2018).

34. Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions [internet]. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Abstract 47LB. Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&&crd_fl=0&ssmsrq=1522772955419&ctms=5000&csmsrq=5001(accessed 4 April 2018).

35. Black A, Bedford T. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak [internet]. Seattle: Bedford Lab, no date. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/(accessed 15 November 2018).

36. Gisselquist D. Missed signals: not investigating high HIV incidence in pregnant women [internet]. Amsterdam: Social Sciences Research Network, 17 April 2018. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3153795 (accessed 6 February 2019).

37. National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and ICF. South Africa Demographic and Health Survey 2016. Pretoria, South Africa, and Rockville, Maryland, USA: NDoH, Stats SA, SAMRC, and ICF, 2019. Available at: https://www.dhsprogram.com/pubs/pdf/FR337/FR337.pdf (accessed 6 February 2019).

38. Wand H, Ramjee G. Combined impact of sexual risk behaviors for HIV seroconversion among women in Durban, South Africa: implications for prevention policy and planning. AIDS Behav 2011; 15: 479-486. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/20981479 (accessed 28 February 2019).

39. Moodley D, Esterhuizen TM, Pather T, et al. High HIV incidence during pregnancy: compelling reason for repeat testing. AIDS 2009; 23: 1255-1259. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/19455017 (accessed 28 February 2019).

40. Kharsany ABM, Hancock N, Frolich JA, et al. Screening for ‘window-period’ acute HIV infection among pregnant women in rural South Africa. HIV Med 2010; 11: 661-665. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965267/ (accessed 28 February 2019).

41. Dinh T-H, Delaney KP, Goga A, et al. Impact of maternal HIV seroconversion during pregnancy on early mother to child transission of HIV (MTCT) measured at 4-8 weeks postpartum in South Africa 2011-2012: a national population-base survey. PLoS 2015; 10: e0125525. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420458/ (accessed 25 October 2017).

42. Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmissions among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 13 February 2018).

43. Rehle T, Shisana O, Pillay V, et al. National HIV incidence measures – new insights into the South African epidemic. So Afr Med J 2007; 97: 194-199. Available at: http://www.samj.org.za/index.php/samj/article/view/777/247 (accessed 6 February 2019).

44. Padayachee GN, Schall R. Short-term predictions of the prevalence of human iimmunodeficiency virus infection among the black population in South Africa. S Afr Med J 1990; 77: 329-323. Available at: http://archive.samj.org.za/1990%20VOL%20LXXVII%20Jan-Jun/Articles/04%20April/1.2%20SHORT-TERM%20PREDICTIONS%20OF%20THE%20PREVALENCE%20OF%20HUMAN%20IMMUNODEFICIENCY%20VIRUS%20INFECTION%20AMONG%20THE%20.pdf (accessed 29 January 2019).

45. National Department of Health. The 2012 National Antenatal Sentinel HIV & Herpes Simplex Type-2 Prevalence Survey in South Africa. Pretoria: National Department of Health, 2012. Available at: http://www.hst.org.za/publications/NonHST%20Publications/ASHIVHerp_Report2014_22May2014.pdf (accessed 4 February 2019).

46. de Oliveira T, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from a Libyan outbreak, Nature 2006; 444: 836-837. Available at: https://www.nature.com/articles/444836a.pdf (accessed 28 February 2019).

47. Abu-Nasr. AIDS scandal in Libya. CBS News. 20 September 2001. Available at: https://www.cbsnews.com/news/aids-scandal-in-libya/ (accessed 29 November 2018).

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49. Vun MC, Galang RR, Fujita M, 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).

50. World Medical Association (WMA). Declaration of Lisbon on the rights of the patient. Ferney-Voltaire: WMA, 2015. Available at: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ (accessed 11 November 2018).

 

Guardian: Another Fine Press Excess Mess


If I wrote that health facilities may be contributing to the spread of diseases, such as Ebola (or HIV), I’d be accused of spreading scare stories. But because it’s the English Guardian, and it’s about sex in an African country, they can publish with impunity a story with the title ‘Ebola vaccine offered in exchange for sex, say women in Congo‘.

A quick read through the article shows that the title is wholly unmerited. And even the WHO has acknowledged that 86% of people infected with ebola in several hotspots have worked at or visited health centers recently. So the “deep mistrust of health workers” in the DRC may not be as misguided as the Guardian seems to suggest.

The Guardian continues: “Suspicion of authorities and health agencies has further hampered efforts to contain the response”. The Guardian tends to avoid suggestions that suspicion of health agencies is ever justified. They prefer to point the finger at gender based violence, sex, bats, women, corpse touchers, anything to avoid the admission that ebola epidemics cannot possibly be a simple matter of individual behavior, traditional practices, etc.

The article is not an isolated example of the Guardian’s fantasies about exotic sexual behavior, occult practices, primitive people, violent men and hapless female and child victims, without power or agency. Another in the series had the title ‘Women in sub-Saharan Africa forced into sex to pay hospital bills‘, based on research that did not warrant anything so salacious.

A third article in the Guardian screams “Girls are literally selling their bodies to get sanitary pads“, which is a quote from a researcher more anxious to get publicity for her work than to address some very serious issues in developing countries. Read the research in question and you will not come away with the impressions that the Guardian would have us believe.

And a fourth claims that dating apps in Pakistan (a very low HIV prevalence developing country, where several outbreaks of healthcare associated HIV have been described) are leading to an increase in transmission rates (there is no evidence of any correlation, let alone a causal connection, it’s just speculation).

It’s not just the English Guardian that plumbs the depths of tabloid journalism when it comes to ‘Africa’, nor are all the bizarre, not too credible and very badly researched issues always about sex. For example, some may remember reading articles about people on ARVs eating cow dung because they had no other food, in the BBC and elsewhere.

This story was repeated in a few other countries. Less attention was given to a woman who said she made up the story because she was told she would have to come up with something good in order to get money to buy food.

Other stories that seem belittling and (often obviously) untrue include one about men who have anal sex having to use adult diapers, people renting out used condoms and washing them before renting them out again, assumptions about ‘African’ sexuality (which can also be found on the BBC site, for example), etc.

Other news outlets that seem unable to resist trivial, belittling and often simply untrue stories about some African countries include IRIN (condom recycling), and Reuters, whose articles, like the BBC’s, are often used to back up newspaper articles, or are syndicated in African newspapers.

Aside from being insulting and demeaning, especially to people from African countries and women, these stories deflect attention from extremely serious risks that people in developing countries face, such as unsafe healthcare (which has been shown to contribute to outbreaks of HIV, Ebola, TB, hepatitis C and others), lack of sanitary and reproductive health services and supplies, misuse of medicines and many others.

The consequences of such irresponsible reporting by some of the most trusted news outlets go far beyond the often trivial gossip that purports to be news. If healthcare facilities are unsafe, people should avoid them, especially if authorities (and the press) try to cover up and lie about the risks, at least until healthcare associated outbreaks of deadly conditions are investigated and addressed adequately.

But if unsafe healthcare is deadly, so is the press that lies about it, the press that slings muck at anyone who dares to suggest that ‘professionals’ don’t always know best, the press that loves to brand people as ‘denialists’ if they don’t fall in with whatever is currently fashionable in ‘expert opinion’.

WHO’s early AIDS experts misdirected HIV prevention


Michael Merson, the second head of WHO’s Global Program on AIDS and co-author Steven Inrig describe WHO’s early AIDS response in The AIDS Pandemic: Searching for a Global Response.[1] Unfortunately, their otherwise excellent and detailed history ignores a tragic and continuing failure: the decision by WHO’s experts to accept an unknown  number of HIV infections from unsafe healthcare.

This misdirection has continued. Daniel Fernando reviews the confusion that led to this misdirection in a recent article[2]: “Already by 1985, WHO staff declared ‘Heterosexual promiscuity (large number of partners) is the most important risk factor among adult AIDS patients in Africa.’[quoted from page 9 in reference 3]…If iatrogenic transmissions had been taken seriously and addressed early, HIV in Africa would have been different.” (If you want a pdf Daniel’s article, email him at: dfernando@jjay.cuny.edu.)

In a prominent 1986 paper in the prestigious journal Science, the first head of WHO’s Global Program on AIDS, 1986-91, and the subsequent first director of UNAIDS, 1996-2008, wrote [p 962 in reference 4]: “…one cannot expect public health officials to upgrade blood transfusion services to prevent HIV infection when the proposed intervention is likely to cost, per person, approximately 30 times the annual per capita public health budget. Similarly, one cannot hope to prevent reuse of disposable injection equipment when many hospital budgets are insufficient for the purchase of antibiotics.”

As if this wasn’t enough, when WHO’s experts decided to give a pass to unsafe healthcare in Africa, they didn’t know how serious it would be. There was no evidence at the time – and there still is no evidence – to say with any confidence that blood exposures account for not more than 10% or as much as 50% or 75% or more. The almost exclusive focus on sex was and is based on insufficient evidence.

Although Merson and Inrig recount many events in WHO’s early response to AIDS, they all but ignore what WHO’s experts knew and thought about HIV from unsafe healthcare. The index at the end of the book doesn’t even include these terms: “blood,” “nosocomial,” “iatrogenic,” “injections, medical,” and “scarification.”

Unsafe healthcare was and is the forgotten risk. Africans in large numbers are still getting HIV from this forgotten risk. How many? No one knows.

References

1. Merson M, Inrig S. The AIDS pandemic: searching for a global response. Switzerland: Springer International, 2018.

2. Fernando D. The AIDS pandemic: searching for a global response. J Assoc Nurses AIDS Care 2018: 29: 635-641. Article available by request from Daniel Fernando at: dfernando@jjay.cuny.edu. Abstract available at: https://www.sciencedirect.com/science/article/abs/pii/S105532901830133X?via%3Dihub(accessed 9 January 2019).

3. World Health Organization (WHO). Workshop on AIDS in Central Africa: Bangui, Central African Republic from 22 to 25 October 1985. Geneva; WHO: 1985. Retrieved from http://www.who.int/hiv/strategic/en/bangui1985report.pdf

4. Quinn T. C., Mann J. M., Curran J. W., Piot P. (1986). AIDS in Africa: An epidemiologic paradigm. Science, 234(4779), 955-963. Retrieved from https://doi.org/10.1126/science.3022379.

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] with infections concentrating in 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).

2. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Geneva: UNAIDS, 2018. Available at:  http://www.unaids.org/en/resources/documents/2018/HIV_estimates_with_uncertainty_bounds_1990-2016 (accessed 5 January  2019).

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