AFRO-NETS> Africa: HIV/AIDS through Unsafe Medical Care

[Peter Burgess <Profitinafrica@aol.com>]

Africa: HIV/AIDS through Unsafe Medical Care
--------------------------------------------

Dear AFRO-NETS colleagues,

The following was posted recently by APIC. I thought it worth passing 
on. But I also have some concerns that are expressed in a separate 
message

Sincerely,

Peter Burgess
mailto:Profitinafrica@aol.com


--
Subj: Africa: HIV/AIDS through Unsafe Medical Care
Date: 10/8/02 10:07:24 PM Eastern Daylight Time
From: apic@igc.org (Africa Action)
To: apiclist@africaaction.org


Africa Policy Electronic Distribution List: an information service 
provided by AFRICA ACTION (incorporating the Africa Policy Informa-
tion Center, The Africa Fund, and the American Committee on Africa). 
Find more information for action for Africa at:
http://www.africaaction.org

+++++++++++++++++++++Document Profile+++++++++++++++++++++

Region: Continent-Wide
Issue Areas: +economy/development+ +health+ 

SUMMARY CONTENTS: 

This posting contains excerpts of an article from the October issue 
of the Royal Society of Medicines' International Journal of STDs 
(Sexually Transmitted Diseases) and AIDS. The excerpted article is 
more technical and longer than we usually repost. However, the con-
clusion of the authors is important, as it challenges conventional 
wisdom on the relative importance of different means of transmission 
of HIV/AIDS. It is preceded by a brief non-technical summary by Af-
rica Action.

The full article, with 106 footnotes and tables, is available (for a 
fee) on the website of the journal at:
http://www.rsm.ac.uk/pub/std.htm

Another posting sent out today contains excerpts from the National
Intelligence Council report on "The Next Wave of HIV/AIDS."

+++++++++++++++++end profile++++++++++++++++++++++++++++++

Summary by Africa Action of "HIV infections in sub-Sahara Africa not 
explained by sexual or vertical transmission," by David Gisselquist, 
Richard Rothenberg, John Potterat, and Ernest Drucker (see fuller ci-
tation and excerpts from article below)

The arguments in this article imply that Africa's HIV/AIDS crisis may 
be fuelled as much or more by unsafe medical practices as by unsafe 
sex. Briefly, the authors say that the evidence available from an ex-
haustive review of research does not support the standard assumption 
that over 90% of HIV/AIDS in African adults is from heterosexual in-
tercourse. Instead, they argue that (1) the data available is not 
adequate to make good estimates of the relative importance of means 
of transmission, and that (2) the likely proportion of transmission 
through unsafe medical procedures, including injections, transfu-
sions, and other contact with infected blood, is being grossly under-
estimated. 

Speaking with Africa Action, one of the authors, David Gisselquist, 
while stressing that data was not adequate for good estimates, said 
that a review of studies linking HIV in African adults to sexual be-
havior accounts for only about a third of HIV infections, which sug-
gests a very large role for unsafe health care in Africa's HIV epi-
demic. The implications: while safe sex is vital, measures to provide 
safe blood supplies, prevent reuse of unsafe needles, and address re-
lated issues of medical safety, are just as urgent. 

International efforts to address these issues do exist, but are woe-
fully underfunded. See: 
http://www.who.int/bct 
http://safebloodforafrica.org 
http://www.injectionsafety.org


Unsafe medical procedures, it is important to note, are among the 
consequences of poverty in Africa, exacerbated by World Bank and IMF 
policies that have forced reductions in spending on healthcare deliv-
ery, as Africa Action has noted in earlier publications (see "Hazard-
ous to Health" at http://www.africaaction.org/action/sap0204.htm).

Note: technical acronyms and terms used in the article below that 
might not be familiar include: 

* iatrogenic infection: an infection inadvertently introduced through
  medical procedures

* PAF: population attributable fraction, the proportion of a health
  problem (such as HIV) that can be attributed to a particular risk;
  this is calculated from the numbers and percents of people with and
  without a risk who have the health problem

* parenteral exposure or transmission: all exposures or transmission
  through cuts, injections, scarifications, blood transfusions, blood
  tests, etc.

-------------------------------------

International Journal of STD & AIDS
Royal Society of Medicine, October 2002
http://www.rsm.ac.uk/pub/std.htm

EDITORIAL REVIEW

HIV infections in sub-Sahara Africa not explained by sexual or verti-
cal transmission 

by David Gisselquist, PhD, independent consultant; Richard Rothen-
berg, MD, MPH, Department of Family and Preventive Medicine, Emory 
University School of Medicine, Atlanta, Georgia, USA; John Potterat, 
BA, independent consultant; Ernest Drucker, PhD, Dept of Epidemiology 
and Social Medicine, Montefiore Medical Center/Albert Einstein Col-
lege of Medicine, NYC, USA

Correspondence and reprint requests to: 
David Gisselquist 
29 West Governor Road 
Hershey, Pennsylvania 17033, USA
mailto:david_gisselquist@yahoo.com

Summary

An expanding body of evidence challenges the conventional hypothesis 
that sexual transmission is responsible for more than 90% of adult 
HIV infections in Africa. Differences in epidemic trajectories across 
Africa do not correspond to differences in sexual behavior. Studies 
among African couples find low rates of heterosexual transmission, as 
in developed countries. Many studies report HIV infections in African 
adults with no sexual exposure to HIV and in children with HIV-
negative mothers. Unexplained high rates of HIV incidence have been 
observed in African women during antenatal and postpartum periods. 
Many studies show 20%-40% of HIV infections in African adults associ-
ated with injections (though direction of causation is unknown). 
These and other findings that challenge the conventional hypothesis 
point to the possibility that HIV transmission through unsafe medical 
care may be an important factor in Africa's HIV epidemic. More re-
search is warranted to clarify risks for HIV transmission through 
health care. 

Introduction

Within two years after the first AIDS cases were described in homo-
sexual men in Los Angeles in 1981, AIDS was diagnosed in Haitians(1) 
and among Africans in Europe,(2) Zaire(3) (now Democratic Republic of 
Congo [DRC]), Rwanda,(4) and Zambia(5). Unlike AIDS in the US and 
Europe, which seemed concentrated among injection drug users (IDUs), 
men-who-have-sex-with-men (MSM), and hemophiliacs, AIDS in Haitians 
and Africans occurred about equally in women and men, and was found 
among the well-to-do, including those who could afford to go to 
Europe for medical care.

Experts at a World Health Organization (WHO) meeting on AIDS in No-
vember 1983 puzzled over possible channels for HIV transmission among 
Africans and Haitians.(6) While noting that spouses of AIDS patients 
were at risk, experts were undecided about heterosexual promiscuity, 
concluding that "whether persons with multiple heterosexual sex part-
ners are at greater risk of acquiring AIDS is unknown " Meeting par-
ticipants considered that "injections with unsterile needles and sy-
ringes may play a role " WHO's 1983 recommendations focused on ster-
ilization of medical equipment, blood safety, and MSMs.

During 1983-88, researchers in Africa found high rates of HIV preva-
lence among female commercial sex workers (CSWs) and patients at 
sexually transmitted disease (STD) clinics.(7-9) By the end of the 
1980s, a consensus emerged among AIDS experts dealing with Africa 
that over 90% of adult HIV infections in sub-Sahara Africa were ac-
quired through heterosexual contact and less than 2% through unsafe 
injections.(10-13) Unfortunately, this consensus was achieved without 
research to address confound between sexual and medical exposures. As 
Packard, Epstein, Minkin, and others have noted, CSWs and STD pa-
tients have relatively high levels of medical exposures that may be 
channels for transmission of blood borne pathogens.(14, 15) Further, 
the consensus ignored evidence from 1980s research suggesting non-
trivial levels of HIV transmission to African children and adults 
through unsafe injections and other medical care.(16-19)

Observations on heterosexual transmission

During the past decade, researchers have struggled to fit emerging 
facts about Africa's evolving HIV epidemic into the consensus view 
that heterosexual transmission accounts for nearly all adult infec-
tions and that iatrogenic transmission is minimal. Many facts do not 
fit well.

Divergent epidemic trajectories. 

Differences in sexual behavior across countries do not explain dif-
ferences in epidemic trajectories. In some countries and regions with 
high HIV prevalence during the second half of the 1980s, such as DRC, 
Uganda, and Kagera in Tanzania, the epidemic has been stable or de-
clining during the 1990s. In others, such as South Africa and Bot-
swana, the epidemic reportedly doubled in less than two years among 
the low risk population (viz, antenatal women) during the early 
1990s. A series of sexual behavior surveys in 12 African countries 
during 1989-93 shows no apparent correlation between the percent of 
adults in a country reporting non-regular sexual partners in the last 
year and HIV prevalence.(20) A more recent study of sexual behavior 
and HIV prevalence in four African cities reports that partner 
change, contacts with sex workers, and concurrent partnerships were 
no more common in the two high prevalence cities studied than in the 
two low prevalence cities.(21, 22)

Unexplained high implicit rates of heterosexual transmission in Af-
rica. 

The assumption that historic and continuing high rates of epidemic 
increases among African adults are almost exclusively due to sexual 
transmission requires much higher rates of heterosexual transmission 
in Africa than in the developed world. However, a recent study of HIV 
incidence in serodiscordant couples in Africa (only 1.2% reported 
consistent condom use) estimated a rate of transmission per coital 
act of only 0.0011,(23) comparable to rates of 0.0003-0.0015 from 
similar studies in the US and Europe.(24, 25, 26) ... 

Epidemiologists who design computer models to support heterosexual 
transmission's role in fueling Africa's HIV epidemic characteristi-
cally choose and/or adjust assumptions about sexual behavior, rates 
of heterosexual transmission, and/or other parameters to allow the 
model to reproduce observed prevalence.(35-38) These assumptions are 
often distant from empiric observations from African studies. While 
such models show that it is possible to imagine patterns of hetero-
sexual transmission that can "explain" the epidemic, they do not show 
that imagined patterns are realistic.

In one model, for example, Anderson and colleagues assumed a mean 
rate of annual partner change of 3.4.(35) In contrast, surveys in 12 
African countries show unweighted averages of 74% of men and 91% of 
women aged 15-49 years with no non-regular sex partners in the past 
year, and only 3.7% of men and 0.7% of women with more than four non-
regular partners.(20) At about the same time, a survey in Denmark 
found that 19% of adults aged 18-59 years reported more than one sex 
partner in the past year;(39) a survey in France found that 17% of 
men and 7.9% of women aged 18-44 years reported more than one sex 
partner in the past year;(40) and a survey in the UK found that 17% 
of men and 8.4% of women aged 16-44 years reported more than one sex 
partner in the past year.(41) Studies of sexual behavior do not show 
as much partner change in Africa as modelers have assumed, nor do 
they show differences in heterosexual behavior between Africa and 
Europe that could explain major differences in epidemic growth.

Model-builders often use the transmission co-factor effect imputed to 
STDs to generate desired rates of heterosexual propagation. For exam-
ple, Korenromp and colleagues(37) assumed that genital ulcers from 
syphilis or chancroid in either partner enhance HIV transmission by a 
factor of 100 ... These rates are at odds with empiric studies, most 
of which indicate that STDs enhance HIV transmission 2-5 fold. ...

Adult HIV without sexual exposure to HIV. 

During the last 14 years, a number of studies have reported adults 
contracting HIV without sexual exposures to HIV. A study in Zimbabwe 
in the 1990s found 2.1% HIV prevalence among 933 women with no sexual 
experience.(48) In a 1988 study of discordant couples in Rwanda, 15 
of 25 HIV-positive women with HIV-negative partners reported only one 
lifetime sex partner.(49) ... In a 1999 study in South Africa, 6.8% 
of women and 1.2% of men 14-24 years old who reported never having 
sex were HIV positive; however, a validation study found some under-
reporting of sexual activity.(52). ...

When HIV prevalence or incidence is found in adults and adolescents 
with no reported sexual exposures to HIV, it may be assumed that a 
share of the HIV in those who are sexually exposed comes from non-
sexual transmission as well. ...

Observations suggesting medical transmission

HIV-positive children with HIV-negative mothers. 

A study in Kinshasha in 1985 found 39% (17 of 44) of HIV-positive in-
patient and outpatient children 1-24 months old to have HIV-negative 
mothers; only five of 16 (with information) had been transfused.(17) 
... In a later report from Rwanda, 7.3% (54 of 704) of mothers of 
children with AIDS were HIV-negative; transfusions were identified as 
the risk factor for 22 of the 54 children.(54) ... 

Shortfalls in accounting for incidence during antenatal and postpar-
tum periods. 

Studies from seven African countries over the last 15 years show 
rates of HIV incidence during antenatal and/or postpartum periods ex-
ceeding what could be expected solely from sexual transmission (Table 
1).(43, 45, 60-68) ... 

Overall, four studies in Malawi, Zimbabwe, South Africa, and Kenya 
show unexplained HIV-incidence ranging from 5-19 per 100 PYs (person-
years) during antenatal and postpartum periods (see Table 1). These 
rates of unexplained incidence among African women are comparable to 
rates of maternal mortality from puerperal fever of 6% to 16% ob-
served by Semmelweis during 1841-46 in the First Clinic at the Uni-
versity of Vienna's obstetric department.(73) ...

Variation of unexplained incidence from country-to-country and over 
time most notably within the Malawi study suggests that something 
more than simply heterosexual transmission is involved. ... In Ma-
lawi, for example, antenatal and postpartum women seroconverted at 
the rate of 21.3 and 12.8 per 100 PYs in 1990 and 1991, so that 
within one year, prevalence among women who were HIV-negative at 
first antenatal visit was well over half of observed prevalence from 
sentinel surveys of 22% and 26% in 1990 and 1991.(60) ... In other 
words, whatever happens during one or two pregnancies and postpartum 
periods whether iatrogenic or sexual or something else may largely 
account for observed high levels of HIV among low risk women in at 
least some African communities.

HIV infections associated with induced abortions and assisted deliv-
ery. 

In addition to these prospective studies of pregnant and postpartum 
women, some other studies also suggest that health care for pregnant 
women may be a risk factor for HIV. In Congo, among 1,770 women at an 
antenatal clinic in 1987-88, 17 of 282 with a history of induced 
abortions were HIV-positive vs. 54 of 1,488 without for a crude popu-
lation attributable fraction (PAF) of HIV associated with induced 
abortions of 10%; complications from abortions were a common cause of 
hospitalization, which was also associated with HIV infection.(74) 
...

Studies associating African HIV infections with injections. 

At least 15 large studies (with more than 500 subjects or 50 cases in 
a case-control study) of risk factors for HIV prevalence or incidence 
in a general population sample (i.e., not CSWs or patients seeking 
treatment for an STD or other illness) in Africa have reported suffi-
cient data to calculate crude PAFs associated with one or more vs. no 
injections over some period ranging from 4 months to lifetime (see 
Table 2).(16, 19, 77-89) Of the 20 PAFs calculated from these 15 
studies (with PAFs for two samples in five studies), only four are 
below 22%, and the unweighted average is 29%. ... 

Several investigators(19, 85, 90) noted that some of the association 
may be due to people seeking treatment for HIV/AIDS symptoms or STDs, 
but the assertion is not adequately supported by research. ... In a 
parallel survey among 150 health workers, prevalence for those with 
STDs and injections for STDs (47%) was almost double prevalence for 
those with STDs only (24%).(90)

Discussion

The recognition that significant shares of HIV in African adults and 
children cannot be explained on the basis of current knowledge about 
sexual and vertical transmission leaves open several transmission hy-
potheses. There may, for example, be co-factors for sexual transmis-
sion not yet identified that are particularly influential during 
pregnancy or for young women. However, an accumulating body of evi-
dence from Africa and other countries suggests that iatrogenic trans-
mission may explain many if not most of the observations previously 
held to be anomalous and detailed in this review.

HIV survival and transmission through medical instruments. 

HIV can survive in syringes at room temperature for more than four 
weeks.(91) One study found HIV RNA in three of 80 syringes after sub-
cutaneous or intramuscular injections of infected patients; ...

An early prospective study among health care workers estimated the 
probability of seroconversion after work-related percutaneous expo-
sure to HIV of approximately 0.3%.(93) However, a case-control study 
of percutaneous exposures by the Centers for Disease Control (CDC) 
and health authorities in the United Kingdom and France assessed 
risks for deep injuries (6.8% of controls vs. 52% of cases) to be 15 
times greater than for other percutaneous exposures.(94, 95) ... Be-
cause medical injections occasion a deep injury and are not countered 
by antivirals, HIV transmission during unsafe injections may well be 
an order of magnitude greater than 0.3%.(96)

Epidemic of unsafe injections in much of Africa and South Asia. 

In a recent review, Simonsen et al.(97) concluded that the average 
person in the developing world received 1.5 injections per year 
(range 0.9 to 8.5). In the majority of studies reviewed, the propor-
tion of injections that were unsafe was greater than 50%. Despite the 
lack of systematic data collection noted by the authors, these find-
ings were consistent over a range of developing world settings. In a 
companion piece, Kane et al.(98) estimated that 80,000 to 160,000 HIV 
infections occur worldwide each year (two-thirds of these in Africa) 
from unsafe injections. These model-based estimates assume a trans-
mission efficiency of 0.5% through unsafe injections, which as noted 
above, may be an order of magnitude too low. Further, these estimates 
do not consider the concentration of medical injections in certain 
groups (e.g., CSWs, STD patients, pregnant women) and settings with 
high HIV prevalence.

Starting in the 1950s Africans experienced a massive increase in 
medical injections associated with mass injection campaigns targeted 
at yaws, with introduction and spread of parenteral therapies to 
treat other diseases, and with plummeting prices for antibiotics and 
injection equipment.(99) For example, UNICEF administered 12 million 
injections for yaws in Central Africa alone during 1952-57.(99) From 
the 1950s into the 1980s, unsafe injections may have contributed to 
the silent spread of HIV in Africa in much the same way that unsafe 
injections for schistosomiasis and other treatments in Egypt estab-
lished hepatitis C as a major blood-borne pathogen, infecting about 
15% to 20% of the general population at the end of the 1990s.(100) 

Documented iatrogenic outbreaks. 

The unexpected discovery of HIV in a 12 year old Romanian girl in a 
Bucharest hospital in June 1989 led to extensive testing to uncover 
the extent and channels for iatrogenic transmission.(101) Tests dur-
ing 1989-90 found 1,086 HIV-positive Romanian children less than 4 
years old. Medical injections were the only apparent risk factor for 
more than half of these children; fewer than 40% had been transfused 
with untested blood (even so, in 1990 only 0.006% of Romanian blood 
donors were HIV-positive), and fewer than 8% of tested mothers were 
infected.(101, 102)

In the former Soviet Union, about 250 children reportedly acquired 
HIV from hospital exposures in 1988-89.(103) More recently, nearly 
400 children attending a single hospital in Libya apparently con-
tracted HIV,(104, 105) and thousands of paid plasma donors in China 
may have been iatrogenically infected.(106) Smaller iatrogenic out-
breaks have been reported among patients and plasma donors in other 
countries.

Conclusion

Taken together, our observations raise the serious possibility that 
an important portion of HIV transmission in Africa may occur through 
unsafe injections and other unsterile medical procedures. After some 
early interest and research on iatrogenic transmission in Africa, 
most notably in Kinshasha during the 1980s, the topic all but van-
ished from the research agenda. Considering the aggressive reactions 
to evidence of iatrogenic HIV infections in Russia, Romania, Libya, 
and now China, and considering as well international attention to the 
transmission of Ebola virus through health care practice, the absence 
of thorough investigation into documented incidents of multiple HIV 
infections suspected from health care in Africa (e.g., HIV-positive 
children with HIV-negative mothers cited above) is noteworthy. Fortu-
nately, there are recent indications, at WHO(97, 98) and elsewhere, 
of increasing attention to iatrogenic risks of blood-borne microbes. 
To the extent that unsterile procedures in routine medical care rep-
resent a possibly major route of HIV transmission in countries with 
high HIV prevalence, the current tenets on which HIV prevention pro-
grams in Africa are based need reassessment. Though promotion of safe 
sexual practices remains a priority, new interventions may be re-
quired to minimize risk from iatrogenic transmission.

************************************************************ 
This material is being reposted for wider distribution by Africa Ac-
tion (incorporating the Africa Policy Information Center, The Africa 
Fund, and the American Committee on Africa). Africa Action's informa-
tion services provide accessible information and analysis in order to 
promote U.S. and international policies toward Africa that advance 
economic, political and social justice and the full spectrum of human 
rights.

Documents previously distributed, as well as a wide range of addi-
tional information, are also available on the Web at: 
http://www.africaaction.org 

To be added to or dropped from the distribution list write to 
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contact directly the source mentioned in the posting.

Africa Action
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Washington, DC 20002, USA
Tel: +1-202-546-7961
Fax: +1-202-546-1545 
mailto:africaaction@igc.org

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