Chapter 1

Ignoring HIV from healthcare in the worst AIDS epidemics


In most countries outside of sub-Saharan Africa, HIV infects far less than 1 percent of adults, and infections concentrate in injecting drug users (IDUs) and men who have sex with men (MSMs). However, in Africa, parts of the Caribbean, and a handful of countries in Asia and Oceania, HIV does not concentrate in IDUs and MSMs but rather invades the general population, creating what are called generalized epidemics.

In countries with generalized epidemics, HIV risk is a two-way street. Some people are infected by heterosexual partners. Others are infected through blood exposures, including traces of HIV-contaminated blood on skin-piercing instruments reused without sterilization during medical injections, dental care, tattooing, and other healthcare and cosmetic procedures. The proportions of total ‘traffic’ coming from each direction are unknown.

Public health experts have known for decades that healthcare providers in much of Africa and Asia often reused syringes, needles, and other skin-piercing instruments without sterilization. In 1991, the World Health Organization (WHO) prepared a booklet advising United Nations (UN) employees ‘living or traveling in areas where the level of medical care is uncertain’ to


…take special precautions to avoid HIV transmission via blood…

If you carry your own needles and syringes, make sure they are the ones used on you. If you are not carrying your own needles and syringes, avoid having injections unless they are absolutely necessary…

Avoid tattooing and ear-piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized.[i]


In revisions of this booklet published in 1999 and 2004, the Joint United Nations Programme on AIDS (UNAIDS) provided similar warnings to UN employees and their families.[ii] However, in countries with generalized HIV epidemics, where WHO and UNAIDS warn UN staff to avoid HIV from blood exposures, neither WHO nor UNAIDS nor other international or national organization has systematically extended similar warnings to the general public, thus providing incomplete information about risks.


Women at risk


In countries where HIV infections concentrate in IDUs and MSMs, HIV infects several men for every woman. On the other hand, in generalized epidemics, especially in the worst ones, HIV infects more women than men (see Chapters 5 and 6). In Lesotho, for example, among adults aged 15–49 years, HIV infects 26 percent of women compared to 19 percent of men.

High HIV prevalence in women in generalized epidemics is hard to explain on the basis of their reported sexual behavior. Most HIV-positive women in Lesotho, as in other countries with generalized epidemics in Africa, Asia, and the Caribbean, report 0–1 sexual partners in the last year – sexual behavior that is conservative or average relative to other women in those countries, or in the US and Europe for that matter (see Chapter 7). Furthermore, among married women who are HIV-positive, more than half their husbands are HIV-negative in 14 of 24 countries with generalized epidemics (see Chapter 7).

In recent years, the AIDS epidemic has come into better focus. In most countries around the world, the number of new infections per year has fallen from peaks reached in the period 1985–2000. At the same time, treatment is getting better and is reaching more people in low- and middle-income countries. In more than 30 countries with generalized epidemics in Africa, Asia, and the Caribbean, national surveys during 2001–08 have improved—and lowered—estimates of the numbers of people living with HIV infections. But even these lower estimates describe ongoing disasters. Without a vaccine—which is years away, at best—understanding how HIV infects so many people in generalized epidemics is crucial to controlling them.


Unexamined and uncontrolled risks


In the US, Europe, and many other countries, public awareness of risks of acquiring HIV infection from skin-piercing instruments led to government policies that reduced those risks to near zero. No country with reliable sterilization of medical instruments has a generalized epidemic. This poses the question: how much does HIV transmission through blood exposures in healthcare and cosmetic services contribute to generalized epidemics? Unfortunately, no one knows.

Some of the earliest AIDS research in Africa in the mid-1980s found evidence for HIV transmission during healthcare, including many HIV-infected children with HIV-negative mothers (see Chapter 5). Despite this evidence, beginning from the late 1980s, AIDS experts rarely asked or talked about risks to transmit HIV through blood exposures except transfusions and IDU.

During 1999-2003, after WHO had all but ignored HIV transmission through unsafe healthcare for more than a decade, people inside and outside WHO presented disturbing new estimates of the numbers of HIV infections from blood exposures during healthcare (Chapter 8). For example, a review of evidence commissioned by UNAIDS concluded in 2002 that ‘contaminated [medical] injections may cause between 12% and 33% of new HIV infections’ in Africa.[iii] Also in 2002, a WHO team using other evidence estimated that medical injections caused 5 percent of new HIV infections in the world.[iv]

What happened next? UNAIDS suppressed the high (12–33 percent) estimate by not releasing the report. But even with WHO’s lower (5 percent) estimate, medical injections alone were infecting more than one hundred thousand people per year. To find and stop HIV transmission through healthcare, a crucial next step was to look for those estimated infections and for the clinics and procedures that were doing the damage. But that did not happen (see Chapter 9).


Why have AIDS experts ignored HIV from unsafe healthcare?  


From this experience, and from the history presented in the following chapters, I think the major obstacle to recognizing and talking about HIV transmission through blood exposures in countries with generalized epidemics has been conflict of interest. HIV is relatively easy to track – transmission requires sexual or blood-to-blood contact. It does not pass through casual contact (like measles), through the air (like tuberculosis), or through mosquitoes (like malaria). Yet 25 years after scientists developed tests for HIV infection in 1984, no one has traced HIV infections in generalized epidemics to see how many are coming from blood exposures.

      For healthcare professionals, discussion and disclosure of HIV transmission through healthcare could erode public trust and prestige. Investigations could lead to suits and criminal charges. Managers and staff could lose their jobs. Many healthcare professionals have allowed such concerns to influence what they say. Conflict of interest has been especially influential and dangerous in many ex-colonies—and in foreign-funded health aid programs in ex-colonies—due to historic and continuing patterns of paternalism and elitism in public health management.

Healthcare professionals’ lack of attention to HIV transmission through unsafe practices can be compared to the tobacco industry’s attempt to mislead people about risks from smoking. For decades, the tobacco industry published shoddy research showing that smoking was safe. Fortunately, medical researchers—who did not have a conflict of interest with respect to cigarettes—did some honest research, and showed that smoking led to lung cancer and other health damage.

While medical researchers exposed dangers covered up by the tobacco industry, who will expose HIV transmission during healthcare? This is, of course, not an exact parallel – most healthcare professionals work for the common good, and many are saints. But some are not aware, and some people with good intentions can be distracted and misled by self-interest. Moreover, the epidemic’s intersections with racial and sexual issues can confuse people – through unrecognized but nevertheless influential racial stereotypes, and through emotional reactions to relevant sexual and gender situations.


The purpose of this book      


The purpose of this book is to motivate the public, reporters, politicians, and lawyers in countries with generalized HIV epidemics to do what is necessary to protect themselves and to stop their countries’ generalized HIV epidemics. To do so, this book presents a history of the HIV epidemic, with attention to blood exposures, and to what public health managers have and have not done to identify important pathways for HIV transmission in generalized epidemics, and to protect people from HIV transmission through blood exposures.


The structure of the book     


Chapter 2 begins with the passage of viruses that became HIV from chimpanzees, gorillas, and sooty mangabeys to humans, and ends in 1960, when most countries in Africa achieved independence. Colonial healthcare programs spread bloodborne pathogens. Some of this was ‘innocent,’ because doctors were not aware of the risks.

Chapter 3 covers the silent expansion of HIV both in and outside Africa in the period 1960–81. During this period, public health managers in Africa recognized death and disease from bloodborne viruses (including the hepatitis B virus, which leads to liver disease, and the Ebola virus, which causes deadly hemorrhagic fever), but did not adequately address risks of transmitting these and other pathogens through reuse of medical instruments without sterilization.

Chapters 4 and 5 describe emerging ideas about AIDS from 1981, when doctors in California first recognized AIDS, to 1988, when the world’s AIDS experts reached a consensus to overlook HIV transmission through healthcare in generalized epidemics. Chapter 4 deals with the period 1981–84, before the introduction of blood tests for HIV infection. Chapter 5 deals with the period 1984–88, when blood tests allowed people to see who and how many were infected, and to examine risks for HIV infection.

Chapters 6–9 cover the period from 1989 to 2009. During this period, the worst HIV epidemics developed in relatively wealthy and educated populations in Africa, while low-level generalized epidemics emerged in a handful of countries outside Africa (see Chapter 6). Chapter 7 examines weaknesses in the dialogue between AIDS experts and people in countries with generalized epidemics. Experts have not trusted and worked with HIV-positive adults to trace the sources of their infections and thereby to identify the risks that drive generalized epidemics. Chapter 8 reviews estimates of the proportion of HIV transmission through healthcare in generalized epidemics. (If you wish, you can skip some of the more technical parts of this chapter without losing the train of the argument in the rest of the book.) Chapter 9 describes long-term failure on the part of public health managers to address risks of HIV transmission through blood exposures in generalized epidemics.

Looking to the future, Chapter 10 considers how the public, aware of risks, could demand safe care. Money and budgets are secondary issues. Safe care does not have to be much more expensive, and in many situations it may even be cheaper – for example, patients can ask for pills instead of injections. Notably, safe healthcare does not wait for more foreign advice or money. By definition, the solution must be local: When healthcare providers are accountable to an informed local population, healthcare safety is secure.


Additional introductory comments


Several healthcare professionals who read early drafts of this book noted that colonial and post-colonial aid-financed healthcare programs in Africa and Asia reduced deaths and improved the quality of life. This is true: healthcare providers and programs have delivered substantial benefits. But do these benefits somehow balance or excuse the dis-benefits discussed in this book? Setting benefits side-by-side with dis-benefits proposes an implicit choice between unsafe healthcare and no healthcare. But there is a third choice: safe care. Medical schools teach doctors to ‘first do no harm.’ Medical ethics oblige doctors to warn patients about risks. There is no question that healthcare programs deliver benefits. The argument in this book is that healthcare should and could deliver fewer dis-benefits.

The book’s topical focus on HIV transmission through healthcare guides the geographic focus on Africa, India, and other countries with generalized epidemics. This book sidesteps debates about HIV prevention among IDUs and MSMs, as well as the best policies and programs to prevent heterosexual transmission of HIV. The resolution of these debates one way or the other does not make healthcare safe, nor do initiatives for safe healthcare (as described in Chapter 10) threaten programs to stop HIV transmission through sex or IDU. Similarly, I endorse efforts to extend antiretroviral treatment to all people in low- and middle-income countries, but I leave to others debates about how best to do so.

This book refers to all HIV infections acquired from formal and informal healthcare as nosocomial infections (acquired or occurring in a hospital) or iatrogenic infections (from a doctor), even though some of the healthcare settings are markets or streets, and many healthcare providers who administer unsafe invasive procedures are not doctors, and some even have no medical qualifications.

[i] WHO. AIDS and HIV infection: Information for United Nations employees and their families. Geneva: WHO, 1991. Doc. no. WHO/GPA/DIR/91.9. p. 23.

[ii] UNAIDS. AIDS and HIV Infection: Information for United Nations employees and their families. Geneva: UNAIDS, 1999; UNAIDS. Living in a World with HIV and AIDS: Information for employees of the UN system and their families. Geneva: WHO, 2004.

[iii] Randerson J. ‘WHO accused of huge HIV blunder’, New Scientist, 2003, 180 (2424): 8–9.

[iv] Hauri AM, Armstrong GL, Hutin YJF. ‘The global burden of disease attributable to contaminated injections given in healthcare settings’, Int J STD AIDS, 2004, 15: 7–16.