Pre-presentation Question 31.9 million Africans are infected with this life threatening blood-borne virus, first identified in the 1980s*, and for which there is currently no vaccine. Prevalence is 5.3% in Africa & the condition is sometimes transmitted sexually. Mother to child transmission is also possible. The extent of sexual transmission is not clear. Prevalence may be greater than 10% in Tanzania**. What is the virus called? 04/09/20151 * **

HIV: Sexual and Non-Sexual Risks “Mainland Tanzania has a generalized HIV epidemic and the primary mechanism for HIV transmission is unprotected heterosexual sex, which constitutes about 80% of all new infections.” (UNAIDS*) Presentation to Kilimanjaro Clinical Research Institute 14 July 2011 Simon Collery – 04/09/20152*

History What has been happening to HIV in Tanzania, Kenya and Uganda for the past 30 years? 04/09/20153

Hypothetical HIV Prevalence ( ), UNAIDS Data ( ) 04/09/20154

Questions for UNAIDS Was there a massive increase in ‘unsafe’ sexual behavior in the late 1970s and early 1980s, and if so, why did it occur? And why did ‘unsafe’ sexual behavior decrease, equally dramatically, in the early to late 1990s? 04/09/20155

What ‘Drives’ a HIV Epidemic? According to UNAIDS and much of the HIV industry: Men Commercial Sex Work Concurrency But many HIV+ people have had no sex or always use protection (THMIS)* 04/09/20156*

HIV Prevalence Years by Age and Sex (Tanzania AIS 03-04) 04/09/20157http://

More questions Sexual practices vary: do they vary by tribe? What difference does male circumcision make; in Kenya, Tanzania, Rwanda, Cameroon?* What difference does female circumcision make (Kenya DHS)? Why does male to female ratio vary so much (see slide 10)? What about in Tanzania (see slide 10)? 04/09/2015* (Table 7.4)8

HIV Prevalence M/F Ratio & Male Circumcision by Ethnic Group TribeHIV+ Female HIV Prevalence Male HIV Prevalence Ratio Circumcised HIV+ Male % Male Circumcised Luhya (5.3m) Other (6m?) Kikuyu (6.6m) Taita/Taveta (0.3m) Kamba (3.8m) Kalenjin (4.9m) Luo (4m) (n86)21.5 Mijikenda/Swahili (1.9m) Kisii* (2.2m) Maasai (0.84m) Somali* (2.3m) Meru (1.6m) Embu (0.3m) /09/20159Compiled from data and

Tanzania HIV Prevalence & Male/Female Ratio (2007) 04/09/201510Tanzania DHS

Why do we think non-sexual HIV transmission so unlikely (see slide 12)? Are African health services able to guarantee that conditions are sterile? Even UNAIDS doesn’t believe that* How does the distribution of HIV positive people in East Africa compare to access to health facilities? HIV is highest in urban areas and areas with good roads** Up to 90% of pediatric blood transfusions are from donors in Tz, not from the blood bank*** 04/09/2015 * ** [SA article on spatial clusters] *** 11

Model Used to Estimate Modes of Transmission 04/09/201512http://data.unaids.org/pub/BaseDocument/2007/ _mot_genepi_blank_en.xls

East Africa’s Health Services Are UNAIDS right to warn UN employees to avoid health facilities in African countries? "We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere.“* If UNAIDS are right to be cautions, why do they not warn Africans about the risks? 04/09/2015*

Kenya Service Provision Assessment – Items Available for Infection Control 04/09/201514http://

Kenya Service Provision Assessment – Supplies Available for Infection Control 04/09/201515http://

Other Non-Sexual HIV Transmission Routes Tattooing, ear and body piercing Manicure and pedicure Some traditional medical practices Shaving and hairdressing Non-professional services, such as tooth- pulling, wound treatment, etc 04/09/201516

Factors that Increase Vulnerability to HIV Co-factors such as schistosomiasis, malaria, TB and other coinfections (Cohen, Modjarrad, Stillwaggon) Compromised immunity due to high disease burden and malnutrition (Stillwaggon) 04/09/2015 Cohen Modjarrad Stillwaggon 17

What can Tanzania do? Educate and warn people about non-sexual HIV transmission risks, not just sexual risks Investigate instances of non-sexual HIV transmission, especially in infants/children Improve conditions in health and cosmetic facilities (including pharmacies and traditional settings) Trust your fellow Africans when they enumerate the risks they have faced 04/09/201518

What can Health Facilities do? If people say they have faced no sexual risks, find out what risks they did face Test their partner (sexual AND non-sexual) or other people close to them who may be infected (‘partner tracing’) If an infant is infected, test their mother; sometimes the mother is negative – why? If a married woman is infected, is her husband? And is he infected with the same HIV type or a different one? 04/09/201519

Thank You Please feel free to contact me if you would like further information: Simon Collery 04/09/201520