Don't Get Stuck With HIV

Protect yourself from HIV during healthcare and cosmetic services

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

Tanzania: Some Alternatives to Orphanages


In a previous blog I concluded that “Long-term residential accommodation will not provide the child with the conditions they need to develop”, and this view is shared by many people and organizations working in child protection in Tanzania. But it would be a mistake to conclude that current practices can cease without being certain of which alternative strategies can be developed to care for vulnerable children, and avoid separating them from their families.

I don’t claim to be an expert in the field of child protection, and what I have written below is based on a relatively small amount of research and inquiry. I make it available in case it is useful to others doing similar or overlapping work.

I briefly outline a number of alternatives, in no particular order. Some of these activities are already being carried out by NGOs in Tanzania or elsewhere; others are in need of further inquiry; some of them may be practiced but I have not found any details yet (this is just informal research!). The list is by no means exhaustive:

1. Child protection monitoring is lacking in the Tanzanian social welfare system; there are probably too few social welfare officers, with too few skills; more importantly, residential care seems to be one of the few options they consider whenever child protection is involved; many social services are provided by private bodies and there is little that is available nationally
2. Mental health issues in mothers and other family members need to be addressed, especially post natal depression; mental health issues are a common reason cited for children being in institutions, and other research shows that post natal depression is rarely diagnosed, let alone treated
3. Maternal health issues: health problems during pregnancy, delivery and in the months after giving birth are numerous; maternal morbidity and mortality rates are very high in Tanzania; care for the mother must not exclude appropriate care for the child, especially if they are separated; care for the child must involve continued contact with their family
4. Newborn health issues: birth defects, disabilities, developmental problems and doubtless many preventable and/or treatable conditions are common; infant and under 5 mortality very high in Tanzania; where this results in the child being separated from the mother or carer the care must be monitored so that the child is reunited as quickly as possible, and does not lose touch with the family at any time
5. Infant feeding and support for mother/carer/family is an important intervention that has been implemented in various forms in Tanzania for a long time, both large and small scale programs; but this needs to be available to all children, if required; timely programs have prevented a lot of separations of children from their mother/carer, and continue to do so
6. Support and acknowledgement for carers; sometimes the nominated carer has a very low status (social status, legal status, etc) in the family and is not considered to have an integral connection with the child’s welfare; there’s little point in the child bonding with a carer who will soon disappear, to be replaced by another carer, who may have a similarly low status
7. Home support for children with special needs; rare in Tanzania to find any kind of support for children with special needs or their carers; what is available is generally provided by NGOs and other private providers
8. Respite care for carers; such care may be provided by some NGOs but it is rare; informal respite care can be provided by relatives and friends/neighbors but this can carry serious risks, and many carers are completely isolated and without support of any kind
9. Daycare facilities; several NGOs are providing daycare facilities but these are mainly ‘supply driven’, and arise when there is a provider willing to build and run them; being able to send young children to daycare facilities would allow mothers/carers to work without having to worry about leaving their children in riskier circumstances, or leaving them with young siblings, who will then have to miss school
10. Foster care, formal, informal, long and short term; informal foster care is and has been common in Tanzania for a long time, although there is little recognition of the word or concept; there is legislation covering formal foster care but it doesn’t seem to be used much; social welfare tend to be reluctant to try out ‘new’ things
11. Family centered support in the home, eg, financial support, especially where there are indications of poverty, neglect, abuse; families are expected to provide care for children, even children of relatives, also old people, people with special needs, etc; yet many families live in poverty and isolation from healthcare, education and infrastructure; nothing is free when you have no income, so ‘free’ school and healthcare, for example, still involve costs that families struggle to meet, or fail to meet
12. Facilities that care for couples, infant/child and mother/carer, when required; rather than separating infants from mothers or carers in the event of sickness or death, providing facilities that allow them to remain together would significantly increase the child’s chances of thriving and even surviving, and also reduce the risk of separation
13. Specialist facilities for children who can’t be at home; special needs often cannot be addressed adequately at home; sometimes a child has so many needs that the family can’t provide that they must spend some time in a specialist facility; but there needs to be better provision for keeping children in touch with their family if they are separated; at present, maintaining contact between children and families is down to the individual provider
14. Support for childless families, those who have experienced loss, stillbirths, etc; fostering and adoption by Tanzania families should be addressed and those who have lost a child, or families who are childless, are often interested in considering caring for a child who has been separated from their family and cannot return
15. Support for facilities reuniting children with families; generally, once a child has been placed in a facility, little effort is made to consider reuniting them with their family; often, families don’t even visit children once they are in a facility; reuniting them with their families can involve a lot of negotiation and logistics that facilities cannot afford, but reuniting them should always be the first concern for facilities and others working with child protection
16. Working with fathers/birthing partners, to encourage women to consider not being alone during delivery and the days after birth; programs that focus on infants, children or women can effectively exclude men, even antagonize them; working with fathers during pregnancy and birth is only one way of including them and could have a significant impact on the tendency to place children in orphanages; working with fathers to understand and negotiate how they can support their partner through pregnancy and delivery and the early months (putting it prosaically, mothers are often afraid of healthcare professionals, but healthcare professionals are often afraid of fathers who turn up to support their partners!)
17. Investigate cases of ‘abandonment’ and other instances of children being separated; this is a legal/administrative issue that can be very vague when cited as a reason for referring a child to an orphanage; it’s difficult to ‘abandon’ a child without a lot of people knowing about it, so claims of abandonment should be treated with greater caution
18. Investigate cases attributed to ‘alcoholism’, as some of them may be something entirely different, or something treatable, but that drives the alcoholism; the term ‘alcoholic’ can be applied to anyone who drinks, especially when applied to a woman; some residential facilities are funded by churches that preach against even the slightest association with alcohol
19. Follow up HIV and TB infected children to find out why they are in facilities, where they often cannot benefit from funded programs that are available for those conditions; chronic conditions can prove difficult for families to deal with, but many children are successfully cared for at home, given the right support
20. Investigate cases attributed to ‘abuse’ to ensure that there is not some other treatable cause that has been categorized as abuse; families are generally reluctant to discuss abuse openly, so it must be questioned when it is used as a reason for admitting a child to an orphanage; of course, abuse does occur, and there are legitimate reasons for children to be separated from their family, and possibly referred to a facility, a foster family, etc
21. Investigate children for whom there is no identifiable reason for their being in a facility, no problem with the child, no problem with the mother/carer/parents/family; if a child is in a facility and no one is visiting them, they can be left without anyone considering their future care; facilities often don’t have the resources to regularly review children’s care plan and social welfare tend to leave such matters to the facility
22. Promotion of Early Childhood Education where this is not available; many children go to school late for various reasons and this can make it difficult for them to catch up; sending children to appropriate education institutions must become the norm; being in daycare or early schooling is preferable to being at home alone, in the care of young siblings or in the care of people who are neither trained nor motivated to look after the child
23. Promotion of inclusive education in public schools; sometimes the smallest reason can be used for delaying a child’s start at school, such as a very minor impairment or disability; for example, there’s no reason for most children with albinism to stay at home; some children out of school have special needs that can be met at state schools, preferably with appropriate measures where the special needs are more acute; waiting until an institution that can provide for special needs is identified, or until the child is older and can more easily access such an institution, leads to long delays
24. There are tools such as the ‘Child Development and Monitoring Tool’ (from the Suryakanti Foundation), which can help identify, treat and even prevent some conditions that give rise to children having special needs; special needs can include developmental, behavioral, learning, impairments, etc, so it’s important to accurately identify what needs a child has as early as possible

There are many alternatives to ‘orphanages’ and ways of preventing separation of children from their family. But it will be a harder job to assess the needs of every child currently in an institution and reunite them with their family, or care for them more appropriately, than it was to refer them to the institution in the first place. The challenge is to follow Tanzania’s Law of the Child Act to the letter: an orphanage should always be a last resort, and it should not be seen as a permanent solution.

The majority of Tanzanian families are poor, a lot are living below the poverty line, unemployed, unskilled and isolated from services they need to change things for themselves. Orphanages and NGOs, donors and sponsors have long been seen as a lifeline, a way of getting one or more children cared for and educated, perhaps so that they can do more for their family later. If resources and funding are to be reduced in one area of child protection, they must be redeployed elsewhere.

But the proliferation of orphanages in a region such as Arusha has merely led to the expectation that more and more orphanage places will be provided. And children will continue to be referred to orphanages as long as a justification that is acceptable to social welfare can be found. Support, funding and sponsorship need be redeployed in ways that avoid separating families.

This is a working document and it will continue to be developed if people make contributions, comments, criticisms, etc. Thank you in advance!

Why Watoto Kicheko Orphanage is now closed


Supporters and followers of Watoto Kicheko Orphanage will have heard that we are now closed, and we are not admitting any more children. Although there were some big challenges over the four years Watoto Kicheko was open there was only one reason why we closed: the children all had somewhere else to go; most of them (about three quarters) were reunited with their own families. A small number were adopted (4), or were placed in facilities that can best provide for their specific circumstances (3).

Out of 36 children admitted over a four year period, only about 19 probably needed to spend some time in a residential facility. About 7 of them probably needed to stay for a year or more. But about 17 had no convincing reason for being in a residential facility. About 29 out of 36 should have left the facility sooner than they did, and some of them should have left far sooner. Sadly, three of the children died while under the care of the orphanage. No child was ever admitted on the grounds that both parents had died.

A number of children were admitted because they were in urgent need of care, sometimes medium to longer term care. And a few would certainly not be alive today if they had not received the treatment and care they got while they were staying at Watoto Kicheko. For this, we owe a debt of gratitude to the staff of Watoto Kicheko, specialists and staff at Selian Hospital (ALMC), staff from a number of other facilities and a whole host of others who visited, gave advice and assistance, supported us in various ways, sent money, gifts and the like.

The Tanzanian Law of the Child Act is clear that orphanages should be a last resort, once every other option has been considered. For a long time now, orphanages seem to have been treated as the go to place for children. Many of the children, and sometimes their parents or carers, have needs that can be provided without the child being separated from their family. Once a child has been separated, for whatever reason, it can be difficult to reunite them. Being separated from their family is a significant harm in itself, aside from the many risks children in care face. The practice of placing children in orphanages when they have no need to be separated from their family must stop.

Of course, there are situations when a child may need to be separated from a parent, carer, or even their family. Sometimes it is not possible for a child to return to a family member, or even to the family. Caring for children in such circumstances is difficult, as anyone involved in child protection knows. But even urgent measures that need to be taken, emergencies, situations where there are clear risks for the child, etc, must also include a strategy for keeping the child in contact with a carer, someone who will stay close to the child, at least until their future is clear.

Long-term residential accommodation will not provide the child with the conditions they need to develop. Neither disability nor poverty are valid reasons for denying children a family life. If you are involved in researching or working with forms of non-residential care for children, reuniting children who have been in care, alternatives to orphanages and strategies for keeping families together in Tanzania, I would love to hear from you: Simon Collery – collery [at] gmail.com

A Minor Revelation Short of a Pulitzer


Steven Thrasher has made the fascinating discovery that many of the HIV positive, gay men in the US are not white, and he regularly reveals this to “incredulous audiences”.

If he enjoys sharing this so much, perhaps he’d be interested to know that most HIV positive people in some of the country’s southern states are heterosexual and female, as well as black.

Indeed, the majority of HIV positive people in the world are black and heterosexual; and a majority of those black HIV positive heterosexuals are female.

Even though the majority of new HIV infections are among men who have sex with men in the US, HIV prevalence is 7 times higher among African Americans than it is among white Americans.

So HIV among men who have sex with men is, to a large extent, a result of sexual behavior. And HIV among people who inject druts is, to a large extent, a result of reusing injecting equipment.

But HIV among heterosexuals is much less likely to be a result of unsafe sex. Even among men who have sex with men, it’s receptive anal sex that carries the highest risk.

Thrasher laments American art imagining Aids as white and in the past. Yet, imagining it as black, gay, western and in the present fails to include the vast majority of HIV positive people: they are black, heterosexual females, from developing countries; and sexual behavior is unlikely to conform to the common stereotypes of ‘African’ sexuality, either.

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 did 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).

Where to Put Sidibe’s Deckchair?


It’s only two weeks since Michel Sidibe publicly threatened UNAIDS employees ungrateful enough to speak out about sexual and other misconduct by their colleagues. But the media has remained silent. Even the English Guardian, who ran the article, and refers to Sidibe’s speech as ‘bizarre’ in the title, has had nothing further to say about it.

The article appears in the Gates funded ‘Global Development’ section of the newspaper and the following text appears on the same page: “Women’s rights and gender equality – This series highlights issues affecting women, girls and transgender people. It is supported by the Ford Foundation, Mama Cash and the Association for Women’s Rights in Development (AWID). It is editorially independent.” (I especially like the last bit).

The Inner City Press has tried to break the silence. They are a small media outlet which has tried to raise the issue, but has been stonewalled by UN officials. In fact, the same organization has been banned from covering UN affairs and from attending press conferences and similar events. For a time, Google removed Inner City Press from their news, allegedly after pressure from the UN, although this was later reversed.

The Inner City Press has a long history of questioning the UN, which shouldn’t be surprising in a media outlet. But they have now demonstrated how quickly the UN clams up when certain questions are asked, questions that the rest of the media seems to have agreed not to raise. (There’s a Change.org petition to have Inner City’s access to the UN restored).

According to a Guardian article in 2012 a “reporter who works for a small investigative news site, Inner City Press, is in danger of being ejected from the UN correspondents association (UNCA) at the behest of journalistic colleagues.” This refers to Matthew Lee, founder of Inner City Press.

Sidibe and UNAIDS seem to have shifted considerably from the UN Charter’s call for respect for human rights, and the world’s media don’t appear to be too bothered, either. Perhaps this is what the Gates, Ford, Rockefeller and other foundations, whose names appear alongside so many worthy initiatives, are paying for.

Sidibe: I Say What’s Ethical


In 2010 a BBC article reported: “HIV has become the leading cause of death and disease among women of reproductive age worldwide”. We are told that “One of the key issues… is that up to 70% of women worldwide have been forced to have unprotected sex. UNAids says such violence against women must not be tolerated.”

UNAIDS Executive Director Michel Sidibe is quoted as saying: “By robbing them of their dignity, we are losing the opportunity to tap half the potential of mankind to achieve the Millennium Development Goals” and “Women and girls are not victims, they are the driving force that brings about social transformation”. So I assume his objection to forced sex is not just related to the risk of HIV.

But when a senior UNAIDS officer resigns after allegations of sexual harassment and assault, Sidibe weighs in with an attack on ‘whistleblowers’ who made the allegations, saying they “lack ethics and morals”. He also praised the accused official as ‘courageous’ for resigning. The official was not charged with any offence.

Even if the accused, Luiz Loures, was innocent, Sidibe seems to be attacking those who try to report instances of violence against women, protecting those who are accused, and turning a blind eye to those who abuse and pillory the ‘whistleblowers’ (who are really just people reporting a serious crime, but in a specific context, the workplace).

Sidibe has accused a former colleague who spoke out against the behavior of Luiz Loures of lying. These victims of Sidibe’s vicious attacks on anyone who dares to criticize UNAIDS are, effectively, accused of biting the hand that feeds them, a typical response of institutionally sexist institutions that have managed to repress criticism of this kind of behavior for decades.

But these matters have gone way past institutional sexism. Sidibe’s intention is clearly to bully and threaten anyone who wants to work for UNAIDS, but would object to being sexually assaulted, and would report it and fight it.

“We know there are people taking their golden handshake from us here and knowing that they have a job and then attacking us. We know all about that. We know every single thing. Time will come for everything. When I hear anything about abuse of our assets, abuse of our things, I ask for investigation. Maybe these investigations are going on.”

UNAIDS has produced a 5 point plan “to prevent and address all forms of harassment for greater accountability and transparency”, the second point of which is: “an open platform will be created for staff to report on harassment, abuse of authority or unethical behaviour within the organization”. But it sounds very much like those who report such things would ‘lack ethics and morals’, in Sidibe’s view.

It seems clear enough that Sidibe is more concerned about protecting UNAIDS funding, the institution itself and the top jobs than about fighting harassment and forced sex. But I don’t think it’s possible to reconcile the seemingly contradictory positions Sidibe is taking. On the one hand he defends women “forced to have unprotected sex”; on the other he attacks those raising concerns about serious sexual misconduct.

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).

 

Almost Positive: HIV Transmission Modes


Yet another study delves into the socio-economic, behavioral, biomedical and sexual lives of young girls, this time in Malawi. The study identifies 15 factors said to relate, directly or indirectly, to HIV transmission. But yet again, all HIV transmission is assumed to be sexual, all risks are assumed to be risks of sexual transmission, and no non-sexual risks or modes of transmission are considered. (If the link doesn’t work there is an abstract on PubMed).

One of the hopes is that those selling pre-exposure prophylaxis (PrEP) will be able to ‘target’ people thought to be most at risk of being infected. However, there is little point in targeting those who are not at risk, or even those who don’t believe they are at risk. Pre-exposure prophylaxis doesn’t work if people don’t take it frequently enough, and those who don’t believe they face any risk are unlikely to take it at all.

A scatter-gun approach would be very expensive and wouldn’t be very effective. But an approach that ‘targets’ people merely on the basis that they are sexually active is in danger of becoming a scatter-gun approach. So, on the one hand, this study (like many others) shows that most people don’t engage in the kinds of behavior said to carry a high risk of HIV infection (and many who do engage in them remain HIV negative).

But on the other hand, this study fails to acknowledge that the assumption that all risk is, directly or directly, related to sexual risk, is completely unwarranted. It is concluded that PrEP can be ‘targeted’ at women who are at risk, but that more work will need to be done to convince these women that they are at risk, and that that risk is either directly or indirectly sexual. (There’s a favorable commentary on the article on AidsMap.com).

Another study takes up the question of whether most transmission is sexual and, therefore, whether most risk is in some sense sexual risk. It does so by considering similarities among HIV genetic sequences, in order to identify possible sexual links. This study finds that only a small minority of clusters of sequences have identifiable sexual links.

This study goes on to note that there is plenty of useful data available: tens of thousands of people in African countries were followed and thousands of new infections were observed among them, but less than 10% of these were attributable to sexual transmission; also, there have been numerous HIV outbreaks outside of Africa which have been a result of unsafe healthcare (all are documented on this site). Yet, none have been investigated in Africa.

This is not such good news for PrEP, because non-sexually transmitted HIV is likely to be better addressed in other ways. But it could be great news for people in high prevalence countries. Sexual behavior and its determinants are notoriously difficult to influence, but conditions in healthcare facilities should prove more tractable. In addition, people need to be made aware of the non-sexual HIV risks so that they can avoid them, at least until conditions in healthcare facilities are improved.