HIV Superspreaders -Medilinks Africa

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HIV Superspreaders -the need for education and behaviourial change in the medical and pharmaceutical industry.

By John Kiwanuka Ssemakula (MD, MPH), May 22, 2003

Sometimes you read something, you hear a term and it is if a light bulb goes off in your head. SARS the latest new epidemic to grab the headlines has generated a lot of research and some new terms. One of the most interesting is the new term that has been coined “superspreaders”. Apparently some people who harbour the virus are much more infectious than others, where a “normal” SARS infected person would only pass it on to one or two other victims, superspreaders pass it onto dozens or even hundreds of others. The spread of the HIV virus is another classic example of this so called heterogenicity of transmission.

A few people, such as long distant truck drivers in Africa fit the profile. They more than anyone else could have been responsible for spreading HIV across Africa, through their interactions with sex workers who then themselves became superspreaders. Many of the sex workers ply their trade at the bustling commercial truck stops, which are thriving business centres and markets and thus serve as a gateway for HIV into communities.

Public health officials reasoning that the best way to slow the spread of the disease would be to induce behavioural change in sexual practices in this group of superspreaders. Appropriately enough much of the prevention efforts in the fight against HIV/AIDS have been directed at this group of superspreaders, at the same time as other high profile education campaigns are aimed at the rest of the population. This tactic seems to have had some success, most notably in Uganda which using its ABC campaign has managed to stem and then reverse the tide of AIDS.

A feature of all these prevention efforts has been the focus on individuals and communities to change their behaviour, and the implication that if these prevention efforts fail and they get HIV, somehow they are to blame. And while there have been strong moves to remove stigma and blame surrounding AIDS in many nations in recent years, this blame culture still remains pervasive and is of course a by-product of any campaign which focuses on people’s individual behaviour and by extension personal responsibility.

Unsafe medical and health practices as superspreaders.

But there is one community that has not come under enough scrutiny, one glaring omission of prevention and change that has huge implications for the spread of HIV in Africa. And this group may be the superspreaders of superspreaders. I refer to the medical and pharmaceutical community. This is not to say that this spread has been deliberate, though not always unknowingly as a recent story in the New York Times suggests “A division of the pharmaceutical company Bayer sold millions of dollars of blood-clotting medicine for hemophiliacs - medicine that carried a high risk of transmitting AIDS - to Asia and Latin America in the mid-1980's while selling a new, safer product in the West, according to documents obtained by The New York Times.”

This is not the first time or the only time the medical community has been implicated in the spread of HIV/AIDS. In France the same thing happened, thousands of haemophiliacs were infected by contaminated plasma products, products that were known by people in the medical community to be unsafe, another example of unsafe medical practices acting as a superspreader.

Recent research also implicates unsafe medical practices, in helping to spread the HIV-1 virus in West Africa. The research suggests that needle transmission via vaccination campaigns in Guinea-Bissau in the 1960’s at the same time as a civil war was going on, may have helped HIV-1 jump from chimpanzees and spread to thousands of people.

And of course the current controversy raging in scientific circles about the claim that unsafe medical practices via needle and injection transmission in Africa are responsible for at least a significant proportion if not most of the spread of HIV into the general population over the last few years. The greatest of all superspreaders in the HIV epidemic to rival.

There are other spectacular examples of unsafe medical practices acting as super spreaders of disease such as in the case of Hepatitis C, “one of the world’s largest iatrogenic transmission of blood borne pathogens known to date, [occurred during ]the schistosomiasis treatment campaign in Egypt which had infected 10% of the entire adult population with hepatitis C by the mid 1980s” according to Ernst Drucker.

There are clearly precedents for unsafe medical practices via needle and injection transmission acting to spread disease including HIV/AIDS throughout the world. As superspreaders, there is nothing to rival mass vaccination campaigns, or treatment campaigns that are conducted in a less than safe manner. And yet the established scientific community has refused to countenance this as a possibility in Africa, and continue to deny such things are happening in Africa or could be happening, while at the same time acknowledging how under funded, underdeveloped, under manned Africa’s health systems have become in recent decades.

According to the WHO at least 16 billion injections are administered in developing and transitional countries every year. In parts of the world, use of injections has completely overtaken the real need, reaching proportions no longer based on rational medical practice with up to 96% of persons presenting to a primary healthcare provider receive an injection, of which over 70% are unnecessary . Many of these syringes and needles are often re-used without proper sterilization. The proportion of injections given with syringes or needles re-used ranges from 1.5% to 69.4% in transitional and developing countries.

Lest one is any doubt about the potential danger consider this alarming story, “Aids panic at Botswana school” was reported in March 2003 by BBC News Online, saying that, “A senior nurse has been suspended after using a single needle to vaccinate 83 schoolchildren in north- western Botswana. This sparked panic among the parents, in a country where about 39% of adults in the population have HIV, the virus which leads to Aids. Sharing needles is one of the most common ways in which HIV is spread….”

However statements from various respected bodies such as the WHO and UN as well as other senior health researchers in the field reject the notion saying that all their best available research suggests that sexual transmission is the main cause of spreading AIDS in Africa and though transmission by unsafe medical practices (via needles and injections) exists, it is not significant and there is no cause for alarm, the situation is under control.

The dogmatic and dogged stance the established scientific community, to accept the possibility flies in the face of commonsense. Especially given the long history of unsafe medical practices in helping the spread of pathogens, especially blood borne pathogens, albeit inadvertently.

The medical and scientific establishment are acting as an example of a community or population that is refusing to change its behaviour in the face of a clear and present danger to the population. It is a community that is exhibiting much the same kind of denial that has been seen and continues to be seen among civil society in many African nations in their resistance to sexual behavioural changes. Just as in many societies, discussing sex is a taboo subject, likewise in the medical and health community, discussing the iatrogenic spread of disease is a taboo subject. If you don’t talk about it, then you can pretend it does not exist and perhaps it will not get you.

The need for behavioral change education in the medical and health fraternity

Such resistance to behavioral change can only be overcome by a concerted and concentrated educational campaigns. It is ironic, that after so many years of preaching to the masses the need for behavioural change, years of massive educational campaigns, it turns out that educators themselves are sorely in need of education. It is said a little knowledge is a dangerous thing” and this is not a case of “physician heal thyself”, it is more a case of “physician educate thyself”. Plainly over the past few years more than a little dangerous complacency has crept into the minds of HIV/AIDS health researchers; the idea that they know all there is to know about the AIDS epidemic and therefore do not need to consider anything new. All this while at the same time admitting the nature of the epidemic in Africa continues to confound them.

This may all sound very harsh. And in know way do I mean to impugn or disparage the great work that has been done and continues to be done by health workers and researchers in Africa and the world over. But this is not the time for debate. This is clearly something that is easily preventable. Research shows that it would cost $290 million to ensure a clean needle for every medical treatment or vaccination in the world in two years' time, a fraction of the cost of other prevention campaigns.

The WHO says on Injection Safety: “Injections are meant to heal, not to harm. They should only be used safely and when needed. Poor injection practices: are a waste of precious healthcare resources; transmit pathogens on a large scale; reduce productivity through an unacceptably heavy burden of disease; and can be avoided.”

There are three steps to ensuring safe needle and injection use in Africa using the WHO recommendations

1. Changing behaviour of health care workers and patients

2. Ensuring availability of equipment and supplies

3. Managing waste safely and appropriately

But none of this can happen if there is a refusal to acknowledge there is a problem. While there is a need to change the behaviour of health care workers and patients in Africa, there is also a need to change the behaviour and attitudes of the medical and scientific establishment in their approach to HIVAIDS in Africa.