Saturday, October 10, 2009

HIV Transmission in Africa: What More than Sex?

The work of arresting the spread of the HIV epidemic has centered around changing sex practices: reducing the number of partners, encouraging fidelity between partners, delaying the onset of intercourse, preferrably until marriage, and using barriers such as condoms during sexual relations. There has been much discussion over the utility of some of these as compared to others, but not much disagreement over the fact that sex is what the spread of HIV is all about. The Anglican Canon Gideon Byamugisha from Uganda, mentioned in my last post on condom use, first raised the question for me as to whether there might be other activities equally important as sex for the spread of HIV. He referred in his teaching DVD to a scientific paper showing that about 70% of a small cohort of Rwandan women with HIV had a history of only one sex partner who himself was negative for HIV infection. How did the women get it?

In the summer of 2003, Dr. David Gisselquist, then of Penn State University Medical Center, Hershey, and his colleagues published a review of data collected before 1989 on risk factors for acquiring HIV. Across this multitude of papers they reviewed, some of high risk groups and some of the general population, he came to the conclusion that the most common risk factor, accounting for 48% of the HIV, was exposure to injections or procedures in the health care system, defined as either western or traditional health care. About 25-29% of HIV transmission in women, and 30-35% in men were due to sexual behavior. These papers were published in the International Journal of STD and AIDS in the summer of 2003, generating considerable discussion via letters to the editor and other correspondence.

Gisselquist has subsequently been vilified by many but none have adequately contested his review of the data. He himself notes that the data are far from perfect, that in the early days of the epidemic there was little knowledge to improve the precision of the data collected. He still admits that sex may be the predominant form of passage, but that health care of various sorts is so important that it must be addressed, and studied carefully, not ignored as is being done now. What did not happen, but could have, however, was the careful analysis of the data that was collected (such as Gisselquist has now done) and the subsequent careful design of studies to answer the questions it presents. Why did this not happen?

First, as Gisselquist describes it, the data from the US and Europe were very good, showing that homosexual behavior and intravenous drug use were the predominant causes in the industrialized west, with heterosexual behaviors coming in a distant third. But there was good evidence and consensus that homosexuality and intravenous drug abuse were extremely uncommon in Africa and non-contributors to the HIV epidemic. Thus says Gisselquist, "most infections were assumed [emphasis mine, BS] to derive from either sexual or health care exposures. The 90% estimate for adult HIV from sexual transmission hence rested on the belief [emphasis mine, BS] that health care transmission was very low, despite abundant evidence to the contrary." And what about those women who said they had only had one sex partner ever, and he was negative for HIV? They were and are often dismissed as "unreliable historians"--liars.

Several anecdotes suggest the accuracy of Gisselquist's data-driven conclusions. First, Sam Shewmaker, an African missionary born and raised in Zambia, was travelling with his wife between two African countries by land. It was brought to their attention at the border that their cholera vaccinations had lapsed. In order to bring them into compliance with the regulations of the country they were visiting, the health worker at the site went to a jar full of milky liquid to fish out a needle to use in injecting them. Questions arose in their minds: How long has the needle been there? How long has the liquid been there? Was it properly diluted when prepared? How does the worker know which of the many needles was used last? They were able to persuade the worker to spare them the injection with the promise they'd get another on their return to their own doctor in just a few weeks.

In 1985, Dr. Monte Cox, then a missionary in Kenya and now the Dean of the College of Bible and Religion at Harding University's Searcy, Arkansas, campus, took his two year old son to the pediatrician for immunizations. Dr. Cox and his son were waiting in a room with 11 other parent-child pairs when the doctor came into the room with one syringe full of vaccine and began to work around the room injecting one child after another. Dr. Cox's boy was last. "Are you going to use the same needle to inject all the children?" he asked.

Looking at the speaker, then the needle and back to the speaker, the doctor retorted, "Well! Not your child", then left the room, returning a bit later, presumably with a new needle.

In 2004 while speaking in the village of Ateiku in western Ghana, I apologized for having left a slide of a syringe in the section of the presentation on risks for HIV infection, acknowledging that they did not have the problem of IV drug use in their village. A woman on the front row inquired during the question and answer session, "You are right that we don't have any IV drug use in our village, but if addicts sharing needles could spread HIV, wouldn't it also spread HIV when the mid-wife uses the same instrument to test all the women in her clinic for anemia?" I assured the woman that she must see a new lancet taken from an unopened paper before it is used to check her for anemia.

The data Gisselquist has published have powerful possibilities for reducing stigma in us and in Africans. Nobody knows precisely how a given individual got his or her HIV, especially in Africa, though this should not matter, particularly to Christians. People are in need. Many of us have solutions. Sharing is the right thing to do, no matter how someone got infected. Our work involves sharing these ideas with church leaders so that they can be better informed and transformed to be the life-sharing neighbors, both in prevention and in care, that are needed in villages full of disease, fear and death.

And then there's the barbershop.