Stephen F. Minkin
In
a speech in Abuja, Nigeria on August 27th President Clinton came very close to
identifying a taboo subject – the medical transmission of HIV. Mr. Clinton noted
that both AIDS and malaria are increasing in Nigeria, but his staff failed to
advise him on how the two killers are connected. Malaria causes life-threatening
anemia often requiring transfusions. Contaminated blood transfusions are the
most efficient means of HIV transmission.
The
President talked about the need for open and frank discussions about AIDS.
Openness about AIDS in Africa as elsewhere should not only be limited to
discussions about sex. The AIDS epidemic will continue out of control until we
pull our heads out of the sand and recognize that people are exposed to the risk
of HIV infection in overburdened clinics and hospitals without sufficient
resources to ensure sterile procedures and safe blood.
The
United States has been most successful in fighting AIDS at home by preventing
the spread of HIV infection in hospitals and clinics. We invested heavily in
universal precautions, reduced the use of transfusions and screened all blood
and blood products for HIV. Poor Africans are being told to fight AIDS without
the benefit of these wise investments.
Imagine
AIDS in the United States 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 US would
have an overwhelming health problem, with large numbers of women and children
dying from AIDS.
Africans
today are enduring an experiment comparable to the notorious Tuskegee Experiment
that denied treatment to hundreds of African American men infected with
syphilis, a curable disease for forty years. Now millions of vulnerable Africans
are denied access to HIV-free blood and health care that we take for granted. In
Tuskegee then and Africa today a major reason for the denial of standard care is
white peoples’ assumptions about black peoples’ sex lives and health. Surely,
AIDS is sexually transmitted in Africa, but as in the United States there is
much more to the story than sex alone. In Tuskegee the denial of treatment was
deliberate. In Africa the devil is negligence by internationally funded AIDS
programs.
African
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. They start childbirth earlier and
have more children than Americans. 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.
The
problem of pregnancy-related anemia is most serious in areas with endemic
malaria. During pregnancy women lose much of their immunity to the disease. The
problem is compounded by poor diet and the numerous stresses caused by poverty.
Likewise young children who have not yet developed immunity to malaria fall ill
and often need blood.
The
following comments by Charles Obonyo, a Kenyan physician, highlight a reality
ignored by experts and the media covering AIDS:
"It
has become clear in recent years that the prevalence of severe pediatric anemia
requiring blood transfusion, particularly in malaria-endemic regions has
markedly increased. At the same time, the prevalence of HIV among blood donors
is also on the increase, to the extent that safe blood has become a scarce and
rare commodity."
In
the US the greatest risk of HIV infection for heterosexuals is among people
using unsterile needles or women whose sex partners use unsterile needles. In
this country people infected by needles are called “junkies” or IV drug
users. In Africa they are 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 infections are directly related to
blood. Even if we accept these minimal figures, their significance for AIDS
prevention in Africa 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 in Africa will be both ethically dubious and
ineffective.
The
proportions of HIV infection resulting from sex or other causes are not known. A
recent large perspective study in Rakai, Uganda published in the journal AIDS
indicates that that a great deal of previous work on AIDS in Africa was at best
incomplete or drew sloppy conclusions. The study found that people became HIV
positive regardless of their history of exposure to sexually transmitted
diseases (STDs). The Uganda research follows earlier studies showing that many
or most HIV-positive women at outpatient or maternity clinics had no previous
history of sexually transmitted diseases. Such findings run contrary to the
viewpoint that STDs and promiscuity alone account for the fact that Africans are
so vulnerable to HIV/AIDS.
Some
donor countries are doing much more than the United States to protect people
from HIV infection in hospitals and clinics. The German agency GTZ has taken a
leadership role by supporting blood screening in the Congo. However, the US, the
leading global source for AIDS prevention funds, has so far paid scant attention
to the problem. As the major donor, the US virtually calls the shots at both the
World Bank and UNAIDS. This gives Mr Clinton and his successor the opportunity
and responsibility to ensure that future investments are both ethically viable
and effective.
Stephen
F. Minkin is a Coordinator for the Network for Infection Prevention (NIP). NIP
is an Internet based coalition concerned with reducing the spread of HIV and
other diseases from transfusions, injections and invasive medical procedures.
NIP believes that access to safe health care is a human right requiring
investments and training in medical hygiene. Steve is currently writing a book
entitled The Missing History of AIDS. He lives in Brattleboro, Vermont. The
NIP web site address is www. Africa-HIV.org. Please e-mail comments to [email protected]
or write to P.O. Box 6073, Brattleboro, VT 05302