Dangerous distortions?

UNAIDS's Redefining AIDS in Asia: Crafting an Effective Response, a comprehensive review of the realities and impact of AIDS in Asia, misses some vital causes of the spread of the epidemic such as unsafe practices in public health services and makes some faulty assumptions about Asia’s HIV epidemics, say Mariette Correa and David Gisselquist

UNAIDS's Redefining AIDS in Asia: Crafting an Effective Response, a report of the Commission on AIDS in Asia, released in March 2008, was drafted by a commission headed by C Rangarajan, Chair, Economic Advisory Council to the Prime Minister of India.

The Commission's mandate was to analyse the developmental consequences of the AIDS epidemic in the region. If Asia is to achieve the Millennium Development Goal of reversing the spread of HIV by 2015, it requires a concerted plan of action.

According to UNAIDS and WHO estimates, 4.9 million (range 3.7 million-6.7 million) people were living with HIV in Asia in 2007. Some 440,000 people (210,000-1.0 million) became newly infected and 300,000 (250,000-470,000) died from AIDS-related illnesses in that year. AIDS currently accounts for more deaths annually among 15-44-year-old adults than do tuberculosis and other diseases.

Redefining AIDS in Asia has many good points, particularly its calls for more aggressive promotion of generic medicines and for creating enabling environments for marginalised groups, including removal or modification of legislation which leads to harassment of sex workers, drug users, men who have sex with men (MSM) and the service providers who assist them. This is important in the context of most Asian countries, where sex work, drug use, and sex between men remain criminal activities.

However, the document fails miserably on some important issues, as described below.

Faulty assumptions about Asia’s HIV epidemics

The Commission asserts that “men who buy sex (from women)…are the single most powerful driving force in Asia’s HIV epidemics, and constitute the largest infected population group”. This assumption and assertion, which pervades the report, undermines its analyses of Asia’s epidemics, and its recommendations for HIV prevention and for combating stigma.

The statement is transparently not true for most Asian countries. In Indonesia, Vietnam, China, Taiwan, Bangladesh, Pakistan, and Malaysia, injection drug users dominate the epidemic. The view that commercial sex is at the centre of all of Asia’s epidemics is further challenged by unexplained differences in HIV epidemics between Asian countries and between Asian and European countries.

For example, few sex workers in the Philippines or Bangladesh are HIV-positive. In Vietnam and China – as in European countries and the US – sex workers who are not injection drug users have low HIV prevalence. Only in selected Asian countries, in Africa, and in some countries in the Caribbean has HIV infected a large number of sex workers who do not inject drugs. Ignoring differences among Asian countries, the Commission makes one diagnosis (unprotected commercial sex), and recommends one treatment (more condoms for commercial sex).

Yes, unprotected commercial sex is a risk to transmit HIV among sex workers and clients. There is no question that condoms should be promoted for commercial sex. But what else is happening? A lot of evidence suggests that most infections in Indian adults cannot be traced to any of the three (stigmatised) risks that the Commission highlights (injection drug use, commercial sex, and men who have sex with men).

The report states that “In Asia, men who buy sex from women far outnumber drug injectors and men who have sex with men, so this group of men is probably the most important ‘determinant’ of future rates of HIV.” This is followed by estimates for each group. It is unclear how the commission arrived at estimates for each of these groups when it acknowledges a lack of data from several countries in the region.

Further, estimating the number of women in Asia who sell sex, the men who buy it regularly, the number of men who have sex with other men and those injecting drugs ignores the transmission rates of the virus per contact through the different routes and within groups and networks. It also ignores the fact that if sharing of needles and syringes for illegal drug use can pass on the virus so efficiently, the same is true for needles and syringes given for medical care which are reused without sterilisation.

Denial of nosocomial infections

The authors of the report claim to have conducted a thorough review of available information on HIV in Asia. It seems strange that they completely missed abundant evidence that explodes the myth that Asian epidemics are almost solely driven by unsafe sex and injecting drug use.

The document ignores published evidence that healthcare workers accidentally infected approximately 100,000 blood and plasma donors in China,1 hundreds of blood and plasma donors in India in 19892, children in a nursing home in Mumbai,3 etc. The document ignores WHO’s own model-based estimates that unsafe injections account for more than 20% of HIV infections in India.4 It does not acknowledge the hundreds of thousands of married HIV-positive Indian women with HIV-negative husbands.5 The commission also ignores studies, such as the All India Institute of Medical Sciences (AIIMS) study on injection practices in India (supported by the World Bank), which in 2002–03 found that 23.5% of all medical injections were given with reused, unsterile or unreliably sterile syringes and/or needles.6 In India, men and women stand in line for tattoos administered with the same needle and inkpot, and injections to treat sexually transmitted disease are often not sterile.

Promoting stigma against HIV-positive adults, especially women

The report stigmatises HIV-positive people, which is especially dangerous for Asian women. It accepts the reality that “relatively few women in Asia have sex with more than one partner”. However – and this is what is dangerous for women – the document supposes that HIV-positive women in Asia are either injection drug users, sex workers, or had partners who were HIV-positive.

But do all women in Asia belong to these three categories? India's recent National Family Health Survey III found that 39% of married HIV-positive women had HIV-negative husbands (this would be about 200,000 women).7 Very few of these women would be drug users. Thus, the message going out here to their husbands, to their families, to their communities, and to the public at large is that they must have been sex workers, or had extramarital sex. That message is dangerous to HIV-positive women – who may be beaten, killed, abandoned, shunned, lose their children, etc.

Voices of men and women who have been infected with HIV through unsafe blood exposures continue to be ignored. From informal discussions with women who have tested HIV-positive and whose husbands tested HIV-negative, a pattern seems to emerge. These women do not wish to reveal their identities or become a part of positive networks or NGOs due to the stigma they will face – they know that many people will think that they were infected through ‘immoral’ behaviour, even when the women are clear that this could not have been possible. On the other hand, for women whose husbands are HIV-positive or have died of AIDS, there is an assumption that they have got the infection from their husbands. These women are viewed sympathetically, and are considered ‘victims’. It is for this reason that positive networks and NGOs get one side of the picture. We have to rely on other evidence like data from the National Family Health Survey III and from PPTCT to see the frequency of discordant couples where only the women are HIV-positive.

Incomplete strategies for HIV prevention

In its answer to the question ‘What are the best strategies for overcoming the epidemics?’ the document completely sidelines prevention strategies that are not directed towards injection drug users, men who have sex with men and sex workers and their clients.

While the report makes important recommendations to reduce the spread of HIV among vulnerable populations through harm reduction and condom promotion, along with legislation and other initiatives to create enabling environments, it misses key recommendations to stop HIV transmission among people who do not belong to these ‘targeted’ groups. In fact, it ascribes recognised successes in reducing the rate of the spread of the epidemic solely to certain strategies while ignoring others. For example, it credits success in containing HIV epidemics in Cambodia and Thailand to condom promotion, without acknowledging that these countries also improved the safety of their healthcare systems.

Denying routes of transmission that go beyond individual behaviours, and for which the State is accountable, the Commission overlooks several crucial interventions. To contain the spread of the HIV epidemic, it is necessary to have interventions that address all the sources that are responsible for it.

Safe healthcare should be seen not merely as blood transfusion safety and clean needles, it should include all invasive procedures in healthcare. Because government agencies in India, as in some other Asian countries, do not inspect and regulate infection control practices in private healthcare settings, the only way patients can be safe is if they know enough to protect themselves. Thus, the public must be warned about risks to acquire HIV and other blood-borne infections from reused instruments, and encouraged to ask providers if instruments are sterile. When governments do not regulate safety, and if patients and clients are not aware of risks so they can protect themselves, what will stop HIV transmission through trace blood exposures during invasive healthcare and cosmetic procedures?

Investigations of unexplained HIV infections are crucial. It is difficult if not impossible to stop nosocomial (caused by medical procedures) transmission without investigating unexplained infections to find where people with unexplained infections received invasive procedures, and to test others treated at suspected facilities.

In recent years, the governments of Kazakhstan and Kyrgyzstan have discovered, respectively, more than 140 and 70 children infected with HIV through hospital procedures (mostly through reused, unsterile instruments). Prior to that, doctors in Russia,8 Romania,9 and Libya10, troubled by a few unexplained HIV infections in children, launched thorough investigations that tested thousands of children with suspected exposure to HIV during healthcare. These investigations demonstrated the potential for rapid and extensive HIV transmission through healthcare procedures.

In high-income countries, strengthening healthcare systems to prevent the spread of HIV was “one of the central and early responses to the AIDS epidemic … [The] fact that healthcare was not a major source of transmission in wealthy countries did not delay or detract from the importance of these measures. A single healthcare-related HIV infection in developed countries leads to investigations to find and stop the source of infection.”11 It is unfortunate that, to date, no South or Southeast Asian government has investigated unexplained infections in children or in women with HIV-negative husbands, tracing and testing others who might have been exposed to find the extent of the damage.

In the AIDS Asia listserve, Jayne Chu criticises the Commission’s report for ignoring structural vulnerabilities of women to contract HIV infections from sexual partners.12 This criticism can be extended to structural vulnerabilities of women in healthcare settings – a situation which is especially dangerous for marginalised women. Sex workers, especially, have poorer access to and ability to negotiate for safe healthcare.

In facilities where the safety of healthcare is compromised, stigmatised groups like sex workers and STD patients (particularly those with anal STDs) have even poorer access to and are unable to negotiate for safe healthcare. An intervention that is long overdue is to ensure that clinics treating sexually transmitted infections do not transmit HIV. This means warning sex workers and clients about risks; ensuring exclusive use of auto-destruct instruments to inject medicines and to draw blood and exclusive use of single-dose vials and reliable sterilisation (boiling or autoclaving) of reused gloves and instruments.

The blame game

To fight stigma related to HIV, the Asian public needs to know that HIV infections are not a reliable sign of morally stigmatised behaviours (drug use, men having sex with men, or extramarital sex) – ie, that an unknown but significant proportion of HIV infection comes from socially acceptable behaviours, such as seeking health or dental care.

But far from fighting stigma with accurate information, the document blames – stigmatises – HIV-positive adults for sexual behaviour or drug use, ignoring risks in healthcare and cosmetic services. Is this bias to blame the victims due to conflict of interest on the part of health policy planners in WHO, UNAIDS, NACO, and other organisations, who do not want to acknowledge that unsafe healthcare procedures account for an important but unknown proportion of HIV infections? How much say do organisations in Asia – even national governments – have in deciding strategies and priorities given that most of the funding for AIDS programmes comes from external funding? In fact, over the years, though “available resources for funding HIV programmes have increased, the percentage of total HIV expenditure funded out of national budgets has decreased in the 14 surveyed countries—from 60% in 1996 to 40% in 2004”, the report says.

Blaming HIV infections on HIV-positive individuals (due to their own risk behaviour) diverts attention from failure on the part of States and international agencies to ensure that healthcare is safe in Asia and to educate the public about risks with trace blood exposures, so that they can make informed choices when accessing healthcare.

Finally, the document also spreads racial stereotypes, stating as fact that Africa’s HIV epidemics are due to African sexual behaviour. That is a theory that fits racial prejudices but does not fit facts. Studies of sexual behaviour across countries overwhelmingly show African sexual behaviour to be not more risky than European or American behaviour -- and for that matter sexual behaviour varies across Africa without any relation to HIV prevalence.

For how long will the UN and its allies continue to maintain double standards for the countries of Africa and Asia on the one hand, and America and Europe on the other? While in the developed world HIV transmission in healthcare settings is completely unacceptable, the same standards are not followed for countries of Asia and Africa. The inadequate efforts taken by international agencies and donors as well as national governments of developing countries themselves to ensure safe healthcare as a fundamental right suggest a “tacit, widespread acceptance of a two-tiered health system: healthcare must observe the highest standards in wealthy countries, but not necessarily in poorer countries”.13 Notably, when UN staff travel to developing countries, UNAIDS advises them to carry sterile disposable needles for their personal use and to ensure that equipment is sterilised, but withholds similar warnings from the general public in such countries.14

It is unfortunate that the UN and its allies continue to ignore nosocomial infections in Asia, and to indulge in blame games and racial stereotypes in their efforts to "educate" the public about how to stop epidemics in Asia. Who will protect the public against such dangerous distortions? HIV risk is a two-way street: people can get hit with HIV from sex and from blood. Telling people to look one way only when crossing a two-way street is inexcusable.

(Mariette Correa is an independent consultant who has been involved in HIV/AIDS programming for NGOs in Goa and South Asia. David Gisselquist is an economist and independent consultant who has published extensively in scientific journals on the risk of HIV transmission through unsterile healthcare practices)

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