Tag: HIV

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Do medical injections spread HIV in Uganda?

A study by Mishra et al (2008) using data from the 2004-5 Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) suggests medical injections are positively associated with HIV status among Ugandan adults, even after taking into account other HIV risk factors and reverse causality (i.e. HIV positive individuals seek more medical care). Even if iatrogenic transmission is not the primary mode of transmission of HIV today (though Pepin argues it played a pivotal role in the early spread of HIV), this finding is worrisome. The authors conclude:

Our analysis showed a strong positive association between number of medical injections and HIV infection. Receiving frequent medical injections was significantly positively associated with HIV positive serostatus among Ugandan adults. Even after controlling for several potential confounders, and accounting for possible reverse causality from HIV infection to increased use of medical injections, men who received five or more medical injections in the previous 12 months were 2.3 times more likely to be HIV infected, and women 1.5 times more likely to be infected, compared with men and women who received no medical injections.
Our results are consistent with the literature showing a positive association between medical injections and HIV infection (Mann et al. 1986; Deuchert and Brody 2006; Barongo et al. 1992), and provide further evidence that medical injections may increase the risk of HIV infection.

…our finding of consistent and strong positive association between multiple medical injections and HIV infection reinforces the need to strengthen programs to promote injection safety and reduce non-sexual modes of HIV transmission. Medical injection as a potential mode of HIV transmission deserves continued research and programmatic attention. Program priorities for Uganda may include focus on rational use of injections, implementation of the national injection safety guidelines, and further scale up of medical injection safety programs.

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2012: the raw and promising new year

Best wishes to you and yours as we bring 2011 to a close and ring in the new year. Thanks for reading and sharing, and I look forward to another year with you in 2012.

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An excerpt from my final column of 2011 for The Independent (Rwanda Edition):

Shuffling through memories of the past twelve months, one is reminded of the heaving, tumultuous and heady days that made up the molding of global and local politics, innovation, and society. Almost every year feels exceptional at its end, and this one is no different. Exceptional for the unexpected uprisings, reassuring surprises, and most of all, the untimely, or perhaps just sobering, deaths.

A remarkable feature of the human brain is that emotion triggers extraordinary powers of memory – emotional events, traumatic or ecstatic, are captured in a different way from ordinary occurrences. I have many such memories this year. I can recall vividly the walls and tables of a classroom at the moment I heard that Tunisia’s Ben Ali stepped down, the living room and footage on Al Jazeera of Mubarak’s fall, the computer screen announcing Bin Laden’s death, and the Twitter feed of my phone as I scrolled through news of Gaddafi’s brutal demise early one morning, all in 140 characters or less. I also recall the unusually grey and rainy Palo Alto morning marking the first day in 57 years of a world without Steve Jobs, just a few days after the passing of Wangari Maathai. I see clearly the words of Christopher Hitchen’s last column staring back at me, in stark and final relief.

There are of course many other memories, moments captured with friends and family, as well as moments alone, preserved not as events in their entirety, but as a series of snapshots. At the end of every year, as now, there is more time to sit and shuffle through them. It feels like an exceptional year, and the past ten have felt like an exceptional decade.

The pace of progress, innovation, and change makes each decade, and increasingly, each year, feel remarkably different from the previous. In the first decade of the twenty-first century, we experienced tremendous economic growth worldwide, a sharp break from the previous several decades. By the mid-2000s, nearly every single country in the world experienced positive economic growth. The number of new infections of HIV is falling by the year, and deaths due to HIV peaked in sub-Saharan Africa and worldwide in 2004/5. Around the same time, Google went public, and together with Facebook, is now a household name in the global village. Mobile phone use has increased exponentially worldwide. In 2000, there were 12 mobile phone users for every 100 people. Today, there are around 69 mobile phone subscribers for every 100 individuals around the globe.

Change, therefore, is brazenly constant. Anyone who suggests otherwise is either deluding themselves or not paying attention. This is as true in Africa as in the rest of the world, although many both in and outside of the continent have been slow to recognize that the former has not, in fact, been standing in place while the latter dashes on.

The churning and surging marketplace for ideas is open. The stepping-stones placed by yesterday’s innovators serve as a launching pads for vaulting into the next year and decade. Even in the destruction strewn by mad and ordinary men lie the pieces that will build society anew. One can pick them up, or stargaze at glittering towers and soaring skylines far from home.

Entering the new year, we are without many of those who began 2011 with us just one year ago. The most memorable deaths on the news circuit were violent, painful, or both, untimely or just-in-time. The world is short a few tyrants, but short a good many great and beautiful minds too. Their exit is a reminder of the inexorable march forward that spares no one. There is no standing still, but there are choices, and our own expectations.

Here is to the raw and promising new year.

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HIV in colonial Africa

Online this week in The Independent (Rwanda Edition): How public health efforts likely contributed to the early spread of HIV.

The Tragic Amplifier

Published online December 8, 2011.

This year marks the 90th anniversary, approximately, of the introduction of human immunodeficiency virus (HIV) into the human population. It also marks thirty years since HIV was first scientifically recognized in 1981. Since the 1920s, this virus has spread across the globe and become the HIV/AIDS pandemic we are all too familiar with today. Most people consider the 1980s to be the beginning of the HIV/AIDS pandemic, but the virus had been prevalent in populations living in parts of central Africa for decades before it became a global nightmare.

New evidence from epidemiologist and international health expert Jacques Pepin suggests that human efforts to improve public health in central Africa were critical in facilitating the early spread of HIV, which has since claimed nearly 30 million lives. In the past two decades, massive coordination, mobilization, innovation, and investment have managed to slow the epidemic and save millions. As we mark World AIDS Day on December 1, 2011, HIV/AIDS is a reminder to us all of the tremendous power of human folly, but also of human triumph.

The Origins of AIDS, by Pepin, is a remarkable new book that pieces together the emergence of HIV in the human population, and its subsequent spread across the globe. HIV is the human version of simian immunodeficiency virus (SIV), which has been present in chimpanzee populations of central Africa for hundreds of years. Human contact with chimpanzees led to at least one transmission of SIV to HIV in a human in the early 1920s, most likely a hunter or a cook living in central Africa, where the majority of SIV-carrying chimpanzees live. This transmission alone was extremely unlikely to have triggered an HIV epidemic, and indeed chimpanzee-to-human transmission could have occurred on separate occasions prior to the 1920s, but would not have spread far. An infected hunter may have passed HIV to his family members, but in all likelihood, the virus would have stopped there. Why did HIV begin to spread beyond a few infected individuals in the early 1920s?

Pepin argues that heterosexual transmission, which is the predominant mode of transmission of HIV today, could not alone have led to an outbreak of HIV on a scale that would trigger a pandemic. Thus, there must have been some kind of “amplifier” that allowed for very rapid transmission of HIV to many people at a time. And what was the mostly likely initial culprit in the amplification of the virus? Colonial public health campaigns involving widespread use of unsterilized syringes and needles.

In the 1930s and 1940s, colonial administrations in French Cameroon, the Belgian Congo, and elsewhere began massive public health campaigns to treat various infectious diseases, including yaws, syphilis, malaria, leprosy, and sleeping sickness, using syringes and needles which were not sterilized regularly, if at all (oral tablet versions of treatments were not available for these diseases at the time). Although there are no blood samples from this time period still in existence (the oldest blood sample in which HIV has been detected dates back to 1959, taken from a man living in Leopoldville, Congo, now known as Kinshasa), it is well documented that other less lethal viruses, like Hepatitis C, were transmitted via syringes in Cameroon, Gabon, and the Belgian Congo, among other colonies. It is not difficult to imagine that HIV could have been passed quickly through a population via syringe as well.

One clinic to treat sexually transmitted diseases (STDs) in Leopoldville treated up to 1000 patients a day by the mid-1950s, with documented evidence that medical equipment was not sterilized between patients. To make matters worse, HIV was likely introduced into Leopoldville/Kinshasa at a time when there was a dramatic gender imbalance due to colonial policies. Urban areas like Leopoldville were often the equivalent of “work camps” in which wives and children were not welcome, which resulted in widespread prostitution, further facilitating the spread of HIV through heterosexual transmission.

HIV, which first spread through non-sterile syringes, often in clinics aimed at treating sexually transmitted diseases among men and sex workers in urban areas, kept at a steady prevalence through heterosexual transmission among the same population. In the colonial period, female sex workers, or “free women”, had only a few regular clients each year, but by the time of independence, female prostitutes would often see up to 1000 clients per year. This new type of prostitution greatly facilitated the transmission of HIV to populations beyond urban areas, and spread along major trades routes and cities in central and eastern Africa, including Kigali.

By 1984-85, Kigali, which at the time had a high ratio of males to females, and thriving prostitution, had the highest recorded HIV prevalence in the world, with 80 percent of prostitutes, 50 percent of STD patients, and 15-20 percent of blood donors, factory workers, and hospital employees testing positive for HIV. By 1987, HIV prevalence was at 17.8 percent in urban areas and jumped to 27 percent in urban areas by 1996.

From central Africa, HIV soon spread to Haiti, before being transmitted via multiple routes to the United States and beyond. Today, 34 million people are living with HIV/AIDS, and another 29 million have perished. That the spread of this virus was likely facilitated, and perhaps only possible, with the help of human technology and early public health campaigns should give us pause, and remind us of the terrifying potential for destruction due to human folly. As Pepin writes, “When humans manipulate nature in a way that they do not fully understand, there is always a possibility that something unpredictable will occur.”

Turning the tide on the spread of HIV/AIDS has taken decades, and millions have tragically lost their lives in the process. But the HIV/AIDS epidemic also demonstrates the amazing power of human innovation and cooperation that can take place on a global scale. Today, there are 6.6 million people receiving life-saving antiretroviral treatment, and both AIDS-related deaths and new HIV infections are declining in most parts of the world. The time, research, energy and money that have gone into tackling HIV has been phenomenal. If anything, we are now in danger of devoting too few resources to other health challenges that must also vie for the attention of the global health community and domestic health budgets.

HIV/AIDS is an extraordinarily painful reminder of the good intentions that can pave the road to hell, and of the unique capability of humans to create as well as destroy.

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Throwing aid at HIV

Some colleagues at APSA shared a new paper by Nunnenkamp and Öhler investigating the effect of official development assistance (ODA) on HIV-related health outcomes in developing countries. The authors write:

Optimally, ODA would help prevent new HIV infections as well as provide better care for the infected. Our results indicate that ODA-financed prevention has been insufficient to reduce the number of new HIV infections. By contrast, we find evidence of significant treatment effects on AIDS-related deaths for the major bilateral source of ODA, the United States.

However, the treatment effect proved to be insignificant when multilateral organizations represented the major source of ODA. In particular, our findings are in sharp conflict with claims of the most important organization in this field—the Global Fund to Fight AIDS, Tuberculosis, and Malaria—that its performance-based support has saved almost five million lives by the end of 2009.

It seems HIV/AIDS related foreign aid is coming under increasing scrutiny these days, at least by academics. Like Bendavid and Bhattacharya (2009), Nunnenkamp and Öhler find U.S.-funded PEPFAR associated with reduced deaths due to HIV/AIDS, but not reduced prevalence of HIV. The inability of billions of dollars to reduce new infections is troubling indeed.

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PEPFAR in Africa: Success or Failure?

My friend and co-author, Melissa Lee, is presenting our paper, “PEPFAR in Africa: Beyond HIV/AIDS”, today at the 2011 American Political Science Association annual conference. I have long wondered whether such a huge influx of health aid targeting a particular disease has a negative effect on the rest of the health sector. So, sometime earlier this year, Melissa and I decided to try to find out!

In our paper, we find that immunization and under-5 mortality rates in African PEPFAR recipient countries improved significantly less than in African non-recipient countries with HIV epidemics. The paper has not been uploaded yet, but I will share the link as soon as it is available.

The President’s Emergency Fund for AIDS Relief (PEPFAR) was initiated by President Bush in 2003, and is the largest bilateral aid program in the world that targets a single disease. By 2011, the U.S. government had committed $39 billion to the program, which often constitutes a large percentage, if not the majority, of health funding in PEPFAR recipient countries.

Empty corridors: rural hospital in Western Uganda, where PEPFAR spends more on HIV than the government spends on health

PEPFAR’s initial goals focused on prevention and treatment of HIV/AIDS, although they have recently expanded their strategy to include integrating PEPFAR into more general health programs. How successful has PEPFAR been in achieving these goals? They have helped provide anti-retroviral treatment to 3.2 million people, prophylaxis for 600,000 HIV+ pregnant women to prevent mother-to-child transmission, and supported 11 million people through other activities.

But a real evaluation of how well PEPFAR has performed must include a comparison to how well PEPFAR recipient countries would have performed in the absence of PEPFAR. Of course there is no way to go back in time and re-do history, but Eran Bendavid and Jay Bhattacharya in their 2009 paper use a difference-in-difference approach (as do Melissa and I) to evaluate the effect of PEPFAR on HIV outcomes such as HIV deaths, HIV prevalence, and the number of people living with HIV among African countries with an HIV epidemic. They find that while PEPFAR appears to have reduced deaths due to HIV/AIDS, HIV prevalence did not improve significantly in PEPFAR recipient countries when compared to non-recipient countries.

All told, the evidence on the effect of PEPFAR on both HIV and non-HIV health outcomes is mixed. Much more work needs to be done to determine why PEPFAR has been unable to reduce the prevalence of HIV, and the channels through which it negatively affects non-HIV related health outcomes such as child mortality and immunization rates.