AFRO-NETS> Non-sexual transmission of HIV overlooked in Africa, Asia

[Nance <nance@aids-bells.org>]

Non-sexual transmission of HIV overlooked in Africa, Asia
---------------------------------------------------------

"Non-sexual transmission of HIV has been overlooked in developing 
countries" wrote three experts in the BMJ, Jan 26 (quoted in the CDC 
Daily Summary). They make the point that nosocomial transmission, and 
use of sharp instruments not properly sterilized and contaminated by 
HIV, may have had, and still have, an important role in HIV transmis-
sion in poor countries. They also note that in the early days of the 
global AIDS plans, there was a lot more emphasis and research, nota-
bly at WHO itself, on this question and then it was downplayed. Re-
cent experience in India's AIDS epidemic indicates that this topic is 
indeed important. Could we have a discussion on this? Surely if the 
British Medical Journal publishes this letter, we could consider it 
fit for debate? 

Yours truly,
Nance
mailto:nance@aids-bells.org


--
BMJ 2002; 324:235 (26 January)

Letters

Non-sexual transmission of HIV has been overlooked in developing 
countries

EDITOR 
Accumulating evidence undermines the belief that heterosexual trans-
mission in developing countries has as large and that unsterile medi-
cal equipment has as little a role as supposed by many HIV experts. 
In 1983 the World Health Organization identified contaminated sharps 
but not heterosexual promiscuity as a risk factor for HIV in tropical 
countries.[1] During the next five years, however, high rates of HIV 
infection were reported in female sex workers and patients at clinics 
for sexually transmitted diseases.

By the late 1980s a consensus had emerged that more than 90% of adult 
HIV infections in sub-Saharan Africa were attributable to heterosex-
ual contact, and only about 2% to contaminated sharps. This consensus 
was forged in the absence of empirical studies controlling for con-
founding between sexual and medical exposures, and despite the fact 
that unsafe injections are common in developing countries. [2,3] More 
important, inquiry into iatrogenic transmission all but disappeared 
from the HIV research agenda, and routine epidemiological reports 
from developing countries not to mention meta-analyses and evalua-
tions of intervention trial shave often been silent about non-sexual 
transmission. [4,5]

The literature indicates that researchers have undervalued data 
pointing to a significant role for medical transmission. Many stud-
ies, particularly from Africa, report unexplained high rates of HIV 
incidence during antenatal and postpartum periods, implicating noso-
comial exposure. They also report that 20-40% of HIV infections can 
be attributed to injections by univariate population attributable 
risk calculations; non-trivial rates of HIV in sexually inexperienced 
adults; and many HIV positive children with HIV negative mothers.[w 
1-30] In addition, the frequent lack of association between sexual 
behaviour variables and HIV trends, and the low rate of penovaginal 
HIV transmission in studies of serodiscordant couples in Africa as 
elsewhere, suggest a need to reassess the contribution of heterosex-
ual exposure.

Although cofactors such as sexually transmitted diseases and lack of 
circumcision may boost heterosexual transmission, the levels of such 
covariates and their known influences on transmission do not seem 
sufficient to explain Africa's HIV epidemic. In 1999 public and pri-
vate international health organisations formed the Safe Injection 
Global Network (SIGN), currently headquartered at WHO, to promote in-
jection safety. Our view, which suggests a pivotal role for contami-
nated sharps in the global HIV catastrophe, supports the network's 
efforts to reduce unnecessary and unsterile injections. Adding such 
interventions to efforts for HIV prevention may bring greater success 
than has been achieved to date with a narrow focus on condoms and 
heterosexual transmission.

David Gisselquist, Independent Consultant. 
29 West Governor Road, Hershey, PA 17033, USA

Richard Rothenberg, Professor. 
Department of Family and Preventive Medicine
Emory University School of Medicine
69 Butler Street SE, Atlanta, GA 30303, USA

John Potterat, Independent Consultant.
301 South Union Blvd, Colorado Springs, CO 80910, USA

Ernest Drucker, Professor of Epidemiology and Social Medicine.
Department of Epidemiology and Social Medicine
Montefiore Medical College and Albert Einstein College of Medicine 
111 East 210th Street
Bronx, New York, 10467-2490, USA

References w1-30 are available on http://bmj.com

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