Wednesday, November 18, 2009

And What About the Barber Shop?

The topic has come up at almost every seminar we've done: "What about the barbershop?" Do barbers, through their scissors clippers and other instruments for cutting hair, pass HIV? For many of us this requires some cultural awareness, if not sensitivity. The folks at our seminars generally have very short hair. Some of them shave their heads to avoid the problem of those little, curly hairs heading back toward their point of origin and causing all sorts of problems. And when folks get their heads shaved, they almost invariably get cuts. "Couldn't this spread HIV?"

Well, surely someone has thought of this, but I've never read anything about it. So in Zambia, in 2005, I went to the barber shop one afternoon in downtown Lusaka for a cultural awareness session. With the head barber's permission, I just sat there and watched two or three men get their hair cut by the same barber. Straight razors were not used, but clippers, electric clippers (there are also similar hand-powered clippers used in the bush) consisting of a row of tiny fixed blades coming to a not-so-sharp point, paired with a set of moving blades crossing over their fixed partners very rapidly. Think of 10-15 (I didn't count them) pairs of tiny, adjacent scissors with one blade moving really fast.

Now, these scissors, the blades on the clippers, are normally not just hanging out there. Usually they are separated from the scalp by a plastic guard which can be from either a fraction of an inch to several inches long such that they only cut hair. But, when the objective is a truly shaved head, then the guard must go. Now the blades are directly on the scalp, and any irregularities in that scalp might find themselves in the teeth. And so they do.

As the barber worked across the scalp, first using the shortest guard, then going over once leisurely without the guard, then carefully and tightly trying to get all remaining stubble off the scalp, I periodically saw the customer flinch, jump, express through total body language not unlike being electrically shocked his very short-lived but very evident pain at being cut. Usually two to three times per hair cut. When the customer was finished, after payment was made, the barber picked up a squirt bottle of purple liquid and sprayed the blades, then wiped them with a towel.

"Could I see your bottle?" I asked as he handed it to me. ("Methylated Spirits" it read, and I'm thinking quickly, going back in history and chemistry, "spirits" are drinking alcohol, ethyl alcohol, and the "methyl" is one carbon with three other hydrogens attached, so "methlyated spirits" would be isopropyl alcohol, what we call "rubbing alcohol", or the alcohol on those little pads that is used to clean the arm before you get a shot.) But is isopropyl alcohol deemed adequate for HIV prevention? No. [It turns out I'm probably wrong, with apologies to my professor of organic chemistry, Dr. England. "Methylated spririts" is denatured alcohol, that kind of drinking alcohol that's sold in shot glasses and fifths but with a little methanol, a highly toxic alcohol, added to it to render the ethanol undrinkable. But that combination is not recommended for killing HIV either.]

So ever since that day I've asked of the public health types who should know, and they've assured me that the barber shop is not a problem. And, we would probably expect more men to be infected than women if the barber shop were a significant source. Except that women also get their hair cut with the same kinds of clippers. In Swaziland we were able to ask the epidemiologist whose work was the first to show that circumcision was protective against catching HIV, leading to the current revival of circumcision (men are lining up for a 50% reduction in risk) in Africa. He assured us that the barber shop was not a significant risk, but he may have been distracted by his enthusiasm over shaving another set of heads. The problem is, I've never heard of a study where the question was truly addressed.

Then this year, in Tanzania, an Infectious Disease doc on the scene admitted that he thought it couldn't be brushed off so easily. It is for this reason that you can't get a shave in a U.S. barber shop anymore. At least not in southern California (I haven't asked here in Alabama). When AIDS hit, the cost of adequate sterilization of straight razors outweighed any possible benefit of continuing the services. And while the multiple tiny blades of the clipper may not inflict as deep a cut as the straight razor could, they can cut. They can cause bleeding. They just might transfer HIV. So they are never used "guard-less" in a U.S. barbershop.

The upshot of all this is that while we know a lot about HIV, and about its transmission from human to human, there are many questions that remain unanswered, not even addressed in any formal sense. And Beth has our personal barber clippers, unused for 20 years of California life, in one of those boxes marked "TO GO". One spouse/one barber/one clippers. And always with a guard.