PHA-Exchange> RICH AND POOR THEORIES OF HIV TRANSMISSION

[Steve Minkin]

Dear PHA Friends,

I look forward to comments, feedback and information about your own
observations and experience.

Thanks,

Steve 

-------------------------------------------

RICH AND POOR THEORIES OF HIV TRANSMISSION



By Steve Minkin


Chinua Achebe, the Nigerian novelist, made this bitter observation about Dr
Albert Schweitzer in an essay entitled "An Image of Africa":

Schweitzer says: "The African is indeed my brother, but my junior brother."
And so he proceeded to build a hospital reminiscent to the needs of junior
brothers with standards of hygiene reminiscent of medical practice in the
days before the germ theory of disease came into being. (1)

When it comes to international efforts supporting AIDS prevention, Africans
are often still seen as junior brothers and sisters for whom the germ
theory of disease only applies to their sexual organs.

The United States and Western Europe has been most successful in fighting
AIDS by preventing the spread of HIV infection at hospitals and clinics. We
invested heavily in universal precautions, reduced the use of transfusions
and screened all blood and blood products for HIV.  In contrast many
countries are advised to skip this step and go directly to sex education
and condoms. These too are valuable tools but it is hard for me to
understand how AIDS prevention will be effective without investing in harm
reduction in the provision of medical services. HIV is a germ carried by
blood and lymph as well as semen. This is as true in South Africa as here
in Denmark. Effective HIV prevention must include harm reduction within all
areas of the health sector. 

What are we to make of the fact that World Bank and UN personal are advised
to bring their own disposable syringes in areas with high prevalences of
HIV but clean syringes are not a priority for the World Bank and UNAIDS
prevention. Does this not stink of the junior brother and junior sister
mentality?  To what extent do such attitudes perpetuate a relativist germ
theory of disease and thereby reducing the effectiveness of AIDS prevention
and distorting the research agenda? 

Imagine AIDS in the United States or Europe if we had ignored the potential
for hospitals and clinics to become centers of HIV infection. Suppose we
highlighted condoms and sex education but were haphazard in the application
of universal precautions and blood screening. Suppose our hospitals and
clinics played viral roulette by sometimes using sterile equipment but
often reusing unsterile syringes needles, catheters, specula and other
invasive equipment over and over again. Under these circumstances AIDS in
the US and Africa would look more similar. The rich countries would have an
overwhelming health problem, with large numbers of women and children dying
from AIDS. 

Many people in developing countries face the daunting task of preventing
AIDS without any certainty that the doors to the medical transmission of
HIV have been closed. Data on injections, obstetrics including abortions
and other nosocomial routes of transmission are remarkably absent given the
huge number of invasive procedures in areas with high prevalence of HIV. 

After two decades we still have much to learn about HIV transmission and
prevention. It was not until 1999 that the first large prospective study in
Africa on the relationship between STDs and HIV was conducted. The results,
in Rakai, Uganda, were not as expected. The overwhelming majority of " HIV
seroconversion occurred without recognized STD symptoms or curable STD
detected by screening." (2) The Uganda research follows earlier studies
showing that many or most HIV-positive women at outpatient maternity
clinics had no previous history of sexually transmitted diseases. Such
findings run contrary to the viewpoint that promiscuity alone account for
the fact that Africans are so vulnerable to HIV/AIDS. 

Surely, AIDS is sexually transmitted in many parts of Africa, but as in the
United States and Europe there is much more to the story than sex alone.
The incidence of blood borne HIV is greater countries where women start
childbirth early and have closely spaced pregnancies.  Demand for blood to
treat obstetric emergencies and pregnancy-related anemias are a vexing
problem where the prevalence of HIV among blood donors makes safe blood a
scarce and rare commodity.

Pregnancy-related anemia is most serious in areas with endemic and epidemic
malaria. Likewise prevalence of severe pediatric anemia requiring blood
transfusions, particularly in malaria-endemic regions has markedly
increased along with AIDS. Women of childbearing age, infants and young
children are most vulnerable to the devastation of malaria compounded by
poor diet and the numerous stresses caused by poverty. 

In developing countries women and young children are most vulnerable to
medically transmitted HIV infections. Women of reproductive age get more
injections and invasive examinations than other demographic groups. Usually
they start childbirth earlier and have more children than women in the
West. They need more life-saving transfusions for childbirth complications
and for pregnancy-related anemia. They are also placed at risk because of
medically questionable injections and transfusions. A vexing problem is to
ensure that they get blood when they need it without exposing them to HIV,
Hepatitis B or C, and other diseases. This will require investments in
training, salaries and equipment.  
  
In the US and Europe the greatest risk of HIV infection for heterosexuals
is among people using unsterile needles or women whose sex partners use
unsterile needles. In the US people infected by needles are called
"junkies" or IV drug users. In other parts of the world they are often
called patients. The October 1999 World Health Organization Bulletin
reported that over 50 percent of injections were unsafe in African
countries for which data was available.
 
UNAIDS estimates that 5-10 percent of global HIV infection burden is
directly related to blood. That means millions of infections are at issue.
Even if we accept these minimal figures, their significance for AIDS
prevention in developing countries is much greater. Investing in AIDS
without plugging this hole is like pouring water in a bottomless bucket.
Without safe health care, much of the future spending on AIDS will be both
ethically dubious and ineffective.

For centuries the West has exploited Africa's human and vast natural
resources. Europe and the United States have most often been behind much of
the violence and war that have plagued and ruined much of Africa. It is now
time to make things right. One important step is to support an alliance
ensuring that no woman, man or child is infected by HIV when seeking health
care. 

Here is part of a message I received recently from a friend working in Uganda:

"The one unfinished research item on the HIV transmission occurs in places
such as Mulago Hospital where 70 deliveries are done daily, sometimes without
access to running water and without rubber gloves for the midwives. Mulago
is the best and then when you think of rural hospitals and how much blood
is associated with deliveries and what proportion of the women are
HIV positive..."

Such issues have not been popular within the international AIDS community.
I personally do not understand the global double standard.  Are white
people more vulnerable than brown and black people to HIV infections from
blood or unsterile medical procedures? 

While millions of dollars have been invested in academic studies on sex
risk factors, how many studies or interventions have focused on viral loads
in needles, syringes, scalpels and speculum, catheters, IV drips and
multiple dose vaccines and medicine vials. We need to rule out these
potential sources of HIV transmission.  There is no literature on invasive
medical procedures and the risk of HIV transmission in areas with high
prevalences of HIV. The absence of studies does not mean that there is no
problem of HIV transmission in health centers but suggests that Chinua
Achebe comments are still very relevant today.

Where are the case studies of injection practices and HIV in formal and
non-formal healthcare settings?  What about risks associated with births
and abortions in hospitals? Has anyone looked at cases of postpartum HIV to
search for the sources of infections? Who has looked at surgical patients
and post- operative rates of seroconversion? What about the use of specula
as potential sources of HIV infection, but also as a way of transmitting
genital ulcers? Has anyone clearly ruled out phlebotomy as a means of
transmitting HIV?  It is remarkable how little we know about these
potential routes of transmission nearly twenty years after the modern AIDS
pandemic entered Africa. 

The myth that HIV is a fragile virus is simply not true. The virus can
remain viable and infectious in both wet and dry states for many days:

" Solutions of HIV were analyzed for the presence of infectious particles
and reverse transcriptase activity after exposure to different temperatures
over a three -week period. Competent HIV was no longer detectable after
three to five hours at 56 ºC, after 11 days at 37ºC and was barely
detectable after 15 days at room temperature (20º to23ºC). HIV solutions
that were allowed to dry at room temperature yielded infectious particles
upon reconstitution between three and seven days after the initial drying. (3)

That doesn't seem fragile to me. What I find so astounding is that most of
this work was done so early in the epidemic and yet the myth persists that
the virus is fragile. Next come hospital practices that increase the
infectivity of medical equipment for example the all too common practice of
soaking batches of syringes in weak disinfectant solutions. We know from
the work on IV drug users that this is an excellent way to cross
contaminate syringes. (4) 


Hospital infections are a problem in both rich and poor countries.  In the
United States tens of thousands of nosocomial infections occur every years
despite substantial resources for infection control.  In Bangladesh I
leaned that Dhaka Medical College has the same problem as Maulgo.  15-20
cesarean sections are performed nightly and 25-30 vaginal births. There is
no soap, running water, and gloves. A senior nurse said to me the delivery
rooms are "filthy" but " to our surprise Bangladeshi women do no get
infections " How can poor people not get infected in an atmosphere of
blood, and filth fueled by the overuse of cesarean sections?  The real
message is a political one: Let the rich soak up the medical resources, and
don't worry about neglecting the poor because they are not subject to the
same germ theory of disease. 

I have no doubt that many hospitals in areas with high HIV prevalence have
excellent infection control. But at this point in the AIDS Pandemic we need
to know how many do not, and why. 

It is the responsibility of every government and every health facility to
ensure that no child, or adult is every infected by HIV during medical
treatment.  It is most important to able to document the steps taken every
day to meet this target along with the obstacles standing in the way of
ensuring the application of universal precautions.

When I read in newspapers that billions of dollars are needed to fight
AIDS, I applauded. But then I asked, " how will the money be spent"?  What
proportion will actually go to improving the quality of healthcare where it
is needed and what will be spent in Europe and the United States in the
name of fighting AIDS. One thing I am certain is that billion of dollars
worth of investments in condoms and sex education alone will not solve the
problem.  Certainly HIV is a sexually transmitted disease and in this
respect women are most vulnerable. But HIV is also much more than a
sexually transmitted disease. Again it is women who are exposed to the
greatest risks of medically transmitted infections.



Steve Minkin  8/3/01
niphiv at yahoo.com

 1. Achebe, C 1979, " An Image of Africa" in  Harper MS and Stepto R. B
Chants of Saints , University of Illinois Press  p318

 2. Gray, RH Wawer, MJ Sewankambo, NK et al  " Relative Risk and Population
Attributable fraction of incident HIV associated with symptoms of sexually
transmitted diseases in Rakai district , Uganda " AIDS 1999, 13:2113-2123

3. McGrath M.S. " HIV stability and Methods for Inactivation"> in P.T.
Cohen et al Eds. AIDS Knowledge Base 1990 p 3.1.4-1. See also Resnick L. et
al "Stability and inactivation of HTLV111/LAV under clinical and laboratory
environments JAMA 225, (14), 1986

 4. Koester S et al " The risk of HIV transmission among IV drug users.
Int. J. Drug Policy 1, (6) 2830, 1991

Steve Minkin
PO Box 6073
Brattleboro, VT 05302

Tel -802-254-4472