Unsafe Medical Practices, Not Sex, Main Cause for Spread of HIV in Africa, Studies Say

Africa's AIDS epidemic was fueled not by heterosexual sex, as is commonly thought, but by unsafe medical practices, including injections and blood transfusions using unsterile needles, according to three papers published in the March issue of the International Journal of STD & AIDS, Reuters/Arizona Daily Star reports (Reuters/Arizona Daily Star, 2/20). While most AIDS organizations contend that heterosexual contact has accounted for 90% of HIV cases in Africa, the new study claims that only a third of HIV cases have been transmitted in this manner, while unsafe medical practices have proved to be a "much greater risk" (Laurance, Independent, 2/20). A team of eight researchers from the United States and Germany led by anthropologist David Gisselquist reexamined research on HIV epidemiology conducted in Africa up to 1988 (Gisselquist et al., International Journal of STD & AIDS, March 2003). The researchers state that previous studies fail to account for the fact that HIV transmission in Africa did not follow the same pattern of other sexually transmitted diseases. For example, in Zimbabwe during the 1990s, HIV transmission rates rose by 12% each year, while overall STD rates declined by 25% and condom usage increased, the study says. The study states that modes of transmission other than heterosexual intercourse must have contributed to the rapid spread of the disease, because HIV is more difficult to transmit through heterosexual intercourse than most other STDs. The researchers found that places with the highest levels of risky sexual behavior, such as Yaounde, Cameroon, had low and stable rates of HIV infection. High STD rates are generally associated with poor and uneducated populations, the study says. However, HIV rates in Africa have been highest among those living in urban centers and those with higher income and education levels, populations that also have a higher degree of access to medical care, the study states. Wealthier African nations, such as Zimbabwe, Botswana and South Africa, that have good access to medical care also have high HIV rates, the researchers state (Brewer et al., International Journal of STD & AIDS, March 2003). The study attributes these high rates to the use of contaminated blood in transfusions, the reuse of dirty needles in the administration of vaccinations and injections and the use of improperly cleaned surgical instruments (Independent, 2/20). The authors state that such evidence largely has been ignored because of "the West's preconceptions about African sexuality, the fear that people might lose trust in healthcare and simple disbelief that medical practices could be so unsafe" (Royal Society of Medicine release, 2/20).

Reaction
Many AIDS researchers and policy makers criticized the study's findings. "There was an element of infection through medical interventions," Michael Adler of University College London Medical School said, adding, "But I am extremely doubtful that it could have been as large as they claim," according to London's Times (Hawkes/Dynes, Times, 2/20). "Unsafe sex continues to be the major route of transmission throughout the world [and] we're concerned that a report like this might tend to make people drop their guard and not use condoms," Catherine Hankins, chief scientist at UNAIDS, said (Adcock, BBC News, 2/20). UNAIDS "welcome[d]" the attention being brought to the issue, saying that more resources need to be devoted to ensuring sterile medical care in all countries, but the agency disagreed with the study's findings, noting that it estimates that 5% of HIV infections in Africa are due to unsterile needles. Dr. Christopher Ouma, HIV coordinator for ActionAid in Kenya, said that the study's findings "could have profound implications for our program and Africa in general," adding, "It could lead to serious change in terms of health behavior with people being reluctant to enter hospitals." Ouma also said that the study could encourage some people to practice unsafe sexual behavior (Adcock, BBC News/Accra Daily Mail/AllAfrica.com, 2/20). In an interview with BBC's Radio Four news program "Today," Gisselquist said that measures to prevent the spread of the virus through sexual contact should continue but that "we need to worry about ... covering all the messages we need to cover." Dr. Yvonne Yooter, a medical officer in blood safety and clinical technology at the World Health Organization, said that although the study "overestimates" the degree to which unsafe medical practices have contributed to the spread of the disease, discussion of transmission in this manner will help AIDS organizations and health ministries to "cover all our bases ... [and] make sure that all HIV is going to be prevented through all possible means of transmission." Yooter added that "if the proportion of infection attributable to needles is higher than what we thought, there is a component of good news in that it's easier to give a single use syringe than to change sexual behaviors" ("Today," BBC Radio Four, 2/20). John Potterat, a coauthor of the study, said, "I am excited at seeing all the coverage and I'm glad that it's raising people's dander because they're much more likely to study the issue seriously" (Leider Vogrin, Colorado Springs Gazette, 2/21). "We are acutely aware of and concerned about the situation and do want to work with Gisselquist and others to try and resolve the issues as best we can and to come up with a way forward to find out what the true answer is," Dr. George Schmid of the department of HIV/AIDS at WHO said. WHO and UNAIDS will hold a meeting to address the issue of unsafe injections March 13-14 in Geneva, according to Reuters Health (Reaney, Reuters Health, 2/20).

An audio version of the BBC's "Today" story on the study is available online.