Re: The contribution of blood exposures to India's HIV epidemic

[Guest guest]

Dear Friends at Prayas,

You asked a question on 17 December (message #6673) which we answered on 18

December (message #6680). Your latest message on 19 February (#6920) responds to

an article that we did not write (message #6905), and which we answered (message

#6921). Since you are interested in the debate, you could read our evidence and

arguments in 3 articles available at: http://www.rsm.ac.uk/media/pr219.htm.

Your latest message on 19 February also claims that you had asked two questions

that we have not answered.

But that is the first time you raise these points. In the interests of

maintaining an evidence-based debate, we quote here two paragraphs from your

recent note (19 January):

“1. The statistical model looks flawed and has extreme variables (ranging from a

mild impact on the epidemic to the tune predicted by

existing wisdom to almost an exclusively 'parenteral' epidemic in our country.

We wonder then why the epidemic is so far so contained in India?

2. Why the parenteral mode selects people in particular families, young sexually

active populations only? Why we could not find numerous unexplained infections

among children? Why pediatric infections are around only 10%? etc.”

These paragraphs contain one statement and more than two questions. Here are our

comments and answers:

1a: “The statistical model looks flawed…” Your comment presents no evidence.

Please clarify what you think is flawed, and why.

1b: “We wonder then why the epidemic is so far contained in India?” Epidemic

growth has slowed, but why? It is no doubt a combination of more condom use in

commercial sex, more care with injections, and other precautions. Over the last

15 years, there have been major changes in injection practices, including a big

shift away from glass syringes to plastic syringes. How much of the slow-down in

HIV epidemic growth is due to less blood exposures, and how much to less sexual

transmission? We don’t know, and neither does anyone else.

2a: “Why the parenteral mode selects people in particular families, young

sexually active populations only?” Do you think that HIV infections in India are

concentrated in young people who are ‘promiscuous’, and in their spouses?

That is a stigmatizing assumption, is it not? It is also inconsistent with

evidence. Some of the highest levels of HIV prevalence in the general population

in India – 3.3% among men and 2.5% among women – were reported from a 2003 study

in Bagalkot District. Only 2% of women and 13% of men in Bagalkot reported any

of three risky sexual behaviours (sex with a non-regular partner in the past

year, more than one lifetime partner, and ever paid or received money for sex),

and these three behaviours

seemed to “explain” only about 15% of HIV infections (using standard

epidemiological analysis, the population attributable fraction of prevalent HIV

infections associated with having any vs none of these behaviours was 15%).

Curiously, HIV prevalence was highest in women aged 45-49 years and in men aged

25-29 years. Among occupations, HIV prevalence was highest among agricultural

labourers (6.2%), whereas

for those in business, non-agricultural labour, and salaried employment,

prevalence ranged from 2.8% to 4.4%. (See: India-Canada Collaborative HIV/AIDS

Project (ICHAP). Community-based HIV prevalence study in ICHAP demonstration

project area, key findings. Bangalore: ICHAP, 2004. This study includes

annexures, including annexure 1: detailed tables.)

2b: “Why we could not find numerous unexplained infections among children?”

People have found numerous unexplained infections among children, even without

looking too hard. Dr Singhal has reviewed papers with 68 infections in children

from blood exposures, and 17 unexplained infections. An investigation among

orphans in Mumbai in 1997 documented 7 HIV infections from health care, and in

2005, we found and documented other unexplained infections (see:

http://www.indiabusinessonline.com/ncasa/hivindiareport.pdf.)

You can find unreported cases at just about any big tertiary hospital in South

India. Unlike in Kazakhstan, Libya, Russia, and Romania, no one in India has

pressed to investigate unexplained infections among children. Why not?

2c: “Why pediatric infections are only around 10%” Is this supposed to be an

argument that there are not many nosocomial infections? As already noted, a lot

of unexplained infections have been found among children, but not investigated.

As for nosocomial infection among adults, that is a completely different story.

Adults go to different clinics, where the risks may be greater than for

children. Eg, hundreds of men and women contracted HIV from plasma selling, and

that has not been investigated. Men and women may have been infected through STD

treatment. Women may be infected through antenatal clinics, OBGYN care, and

laparoscopic surgery. Someone should look.

We are asking people to be careful, to protect themselves from HIV. We are also

asking people to realize that HIV is not a sign – STIGMA –of ‘promiscuous’

sexual behavior. And we are asking for investigations, research, and evidence to

determine how much HIV comes from common blood exposures.

Best regards,

Gisselquist

Mariette Correa

Gisselquist <david_gisselquist@...>

Mariette Correa <mariettec@...>