Don't Get Stuck With HIV

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


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

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

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

Evidence HIV-positive adolescents did NOT get HIV from sex

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

table 1 adolescents

Some HIV-positive teens may have gotten HIV from their mothers when they were babies; but without antiretroviral treatment (ART), which arrived late in Africa, survival to adolescence would be unusual. Thus most adolescent virgins with HIV likely got it from blood contacts. If virgins are getting HIV that way, some non-virgins are likely getting it the same way.

Using data from national surveys in Lesotho, Swaziland, and Zimbabwe, and assuming no lying about sexual behavior, Deuchert estimates only 30% of HIV-positive never-married adolescent women aged 15-19 years got infected through sex.[2] What if some lied? Deuchart does the math: “The assumption that HIV is predominantly sexually transmitted is valid only if more than 55% of unmarried adolescent women who are sexually active have misreported sexual activity status.” (Tennekoon makes a similar analysis.[3])

But let’s cast the net wider: During 2003-15, 45 national surveys in Africa reported the %s of (self-reported) virgin and non-virgin youth aged 15-24 years with HIV (see Table 2 at the end of this blog post). Young men and women got HIV whether or not they virgins.

For example, in Congo (Brazzaville), Rwanda, Guinea (2012), Democratic Republic of the Congo, and Gambia, the %s of young women that were HIV-positive was greater among virgins than among all young women. Among young men, the % with HIV was the same or greater among virgins vs. all young men in Tanzania (2007-08), Congo (Brazzaville), Sierra Leone (2013), Guinea (2005), Mali, Sao Tome and Principe, Burundi, Benin, Burkina Faso, Niger, and Gambia.

Across all 45 surveys, the median ratio of the %s of self-reported virgin young men with HIV to all young men with HIV was 0.75 (last line, Table 2). Across all 45 surveys, the median ratio of the %s of self-reported virgin young women with HIV to all young women with HIV was 0.33 (last line, Table 2). And, as noted above, many infections in non-virgins likely came from blood-borne risks.

The only way to say most HIV infections in adolescents in Africa come from sex is to throw away the best evidence we have – to assume survey data are wrong because self-reported HIV-positive virgins are lying. That seems to be what experts at UNICEF, WHO, and UNAIDS have done – ignoring evidence to accuse HIV-positive adolescents of unwise sex, and accusing them also of lying if they say they are virgins.

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

table 2d adolescentstable 2e adolescents

References

1. Brewer DD, Potterat JJ, Muth SQ, Brody S. Converging evidence suggests nonsexual HIV transmission among adolescents in sub-Saharan Africa. J Adolescent Health 2007; 40: 290-293. Partial draft available at: https://www.deepdyve.com/lp/elsevier/converging-evidence-suggests-nonsexual-hiv-transmission-among-105k5VXKQE (accessed 19 December 2015).

2. Deuchert E. The Virgin HIV Puzzle: Can Misreporting Account for the High Proportion of HIV Cases in Self-reported Virgins? Journal of African Economics, October 2011, pp 60-89. Abstract available at: http://jae.oxfordjournals.org/content/20/1/60.abstract (accessed 19 December 2015).

3. Tennekoon VSBW. Topics in health economics. PhD dissertation. Washington State U, 2012. Available at: http://research.wsulibs.wsu.edu:8080/xmlui/bitstream/handle/2376/4270/Tennekoon_wsu_0251E_10484.pdf?sequence=1 (accessed 18 December 2015). See also an earlier paper by

 

 

 

 

 

WHO to Warn About Unsafe Healthcare Transmitted Hepatitis, but not HIV?


UNAIDS, WHO, CDC and other institutions continue their insistence that HIV is almost always transmitted through heterosexual sex in African countries (though nowhere else), and that unsafe healthcare, cosmetic and traditional practices play a vanishingly small and declining role in transmission.

It was suggested to me recently by someone who questions the above views that these well funded institutions will eventually have to change their tune. However, he felt that they would not admit that they are wrong, or that they have known since the 1980s about the risks posed by unsafe healthcare and other non-sexual HIV transmission routes.

Perhaps hepatitis C is the opportunity needed? The WHO is now warning people about the dangers of infection through unsafe blood, medical injections and sharing of injecting equipment. They are also recommending the use of injecting equipment that cannot be reused, rather than equipment that should not be reused, but frequently is.

Unfortunately, the WHO is not very explicit about the problem: there are many health professionals who are unaware about the risks of reusing skin piercing equipment, especially injecting equipment. These health professionals do not warn their patients because they are unaware that they should not reuse syringes, needles, even multi-dose vials that may have become contaminated.

People may be surprised that there are health professionals who are unaware of these risks, or that they take these risks even if they are aware of them. But every year there are cases of infectious, even deadly diseases, being transmitted to patients through careless use of skin piercing equipment. Tens of thousands of people are put at risk, and that’s just in wealthy countries.

As for poor countries, especially sub-Saharan African countries, where the highest rates of HIV are to be found, no one knows how many people have been put at risk, how many have been infected with hepatitis, HIV or other blood borne viruses, or how many are still at risk. People are not being made aware of the risks they face, so they can not take steps to avoid them.

The US National Institute of Allergy and Infectious Diseases (NIAID) still carries the rather limp “HIV cannot survive for very long outside of the body”, instead of warning people that they should not allow the blood of another person enter their bloodstream. It is irrelevant how long these viruses survive; people need to know that contaminated blood may be entering their bloodstream so that they can take steps to avoid this.

Unsafe healthcare, cosmetic and traditional practices carry huge risks, especially in countries where blood borne viruses such as hepatitis, HIV and others are common. People can avoid infection with these blood borne viruses by avoiding potentially unsafe healthcare, unsafe cosmetic practices, such as tattooing or body piercing, and traditional practices, such as circumcision or scarification.

Prejudice Continues to Blind UNAIDS to Non-Sexual HIV Transmission


Perhaps the author means well by speculating about how much ‘sodomy’ there is in Zambian prisons. But articles like this miss a great opportunity to look at possible non-sexual HIV risks in prisons. For example, what are safety standards like in prison health facilities? Do prisoners engage in cosmetic practices, such as tattooing, piercing, even shaving and hairdressing? Do any of them engage in traditional practices that may involve skin piercing or cutting? Do any engage in blood oaths or anything else that could result in a HIV negative person coming into contact with the blood of a HIV positive person?

The article says that “homosexuality is among the six key drivers of the transmission of HIV in” Zambia. One source lists these drivers as: multiple and concurrent sexual partners, mother to child transmission, low and inconsistent condom use, vulnerable and marginalized groups, low rates of male circumcision and mobility and labour migration. Let’s look at each of them in turn.

No non-sexual ‘drivers’ are clearly identified there. But the list is a very weak tool for identifying the risks that many people face, given that prevalence reaches over 20% in the capital, Lusaka, and close to that figure in two other provinces. For example, several articles have shown that having multiple partners does not account for extremely high rates of HIV transmission; concurrent partnerships are no higher in high prevalence areas than in low prevelence areas, but they can not account for very high rates of transmission either, despite the frequent, triumphalist literature spewed out on the subject.

Many women are infected fairly late in their pregnancy or just after giving birth, when they are unlikely to have engaged in any kind of sexual behavior, let alone unsafe sexual behavior; and the partners of many women who seroconvert are HIV negative. In addition, some women are infected by their infant, who could only have been infected by some kind of non-sexual route, such as unsafe healthcare. We have no idea how common this phenomenon is.

HIV prevalence in many countries is higher among those who sometimes use condoms and lower among those who say they never do. Condom use only protects against sexual transmission of HIV, not against non-sexual transmission. The issue of circumcision is highly controversial and it has never been shown that the mass male circumcision programs currently being carried out in high HIV prevalence African countries will have any impact on HIV transmission, except by the use of dubious figures conjured up by those who believe that circumcision is superior to the alternative, which involves not slicing off a healthy piece of genital flesh.

Mobility and labor migration are perhaps more closely related to ‘vulnerable and marginalized groups’ in Zambia because HIV prevalence is exceptionally high among those involved in mining, for example. Many miners are mobile, many are immigrants, and high levels of HIV prevalence means that they are singled out for stigmatization by the HIV industry, which insists that HIV is almost always transmitted through unsafe sex. Therefore these high prevalence groups must be promiscuous, also careless, selfish, predatory and a whole lot of other pejorative things.

The HIV industry continues to stigmatize people who are often already marginalized, blame people who are infected and alienate people who are most vulnerable to suffering from poor health, facing many other hazards relating to health, poverty, education and employment. There are two ‘drivers’ of HIV epidemics, sexual and non-sexual. The industry concentrates on sexual transmission to the almost total exclusion of non-sexual transmission. This needs to be addressed if countries like Zambia are to reduce HIV transmission, especially in prisons and mining areas, and eventually eradicate it altogether.

[For more about non-sexually transmitted HIV through unsafe healthcare, cosmetic and traditional practices and how to protect yourself, visit the Don’t Get Stuck With HIV site.]