Debate Over HIV Transmission Through Unsafe Medical Practices May Impact AIDS Funding Allocation

A debate over the role of unsafe medical practices in the transmission of HIV in sub-Saharan Africa may impact how AIDS resources are allocated, the Christian Science Monitor reports. Although most AIDS organizations say that heterosexual contact has accounted for most of the HIV cases in the region, new studies claim that unsafe medical practices, such as injections and blood transfusions using unsterile needles, are a much greater threat. The World Health Organization estimates that 90% of HIV-positive people in sub-Saharan Africa have been infected through sexual contact and 2.5% of HIV-positive people have contracted the virus through unsafe injections, according to the Monitor (Crawley, Christian Science Monitor, 10/2). However, three studies published in March in the International Journal of STD & AIDS by a team of eight researchers led by anthropologist David Gisselquist support a theory that unsafe medical practices are the primary route of HIV transmission in sub-Saharan Africa. The same team in May published a similar study in the British Journal of Obstetrics and Gynaecology (Kaiser Daily HIV/AIDS Report, 6/9). The research has sparked a debate over whether funding should go to programs that emphasize sexual behavior change or safer medical practices, including the use of sterile needles. "We can all agree that we should work toward ending unsafe injections. The issue is how many resources we devote right now," Dr. George Schmid, a senior epidemiologist at WHO, said, adding that devoting too much prevention funding to ensuring safe injections would not have a major impact on reducing the spread of HIV.

Findings Disputed
Gisselquist's conclusions are based on a "crude population attributable fraction," a statistical indicator that describes the association of various activities with HIV without showing causality, according to the Monitor. Many researchers have called such measurements unreliable, and Gisselquist has said that it "may overestimate or underestimate the causative association," the Monitor reports (Christian Science Monitor, 10/2). WHO in December 2002 released a report on four different studies examining the role of unsafe medical practices in HIV transmission and concluded that "the lowest attributable fraction calculated on the basis of the data provided ... (8%) exceeds our 2.5% modeled attributable fraction, suggesting that our estimate is conservative" (Kaiser Daily HIV/AIDS Report, 9/24).

Attention Needed
WHO scientists have offered four "key" arguments disputing Gisselquist's claims: HIV prevalence in Africa is low among children and rises "rapidly" with the onset of sexual activity; there is a strong correlation between the number of sexual partners and the likelihood of a person testing HIV-positive; countries that have high HIV prevalence do not also have a high prevalence of hepatitis C, an infection that can be transmitted through contaminated needles; and fewer unsafe injections are administered in each year per person in sub-Saharan Africa than in Eastern Europe, South Asia and the Middle East, where HIV prevalence is lower, according to the Monitor. Observers on both sides of the debate say that regardless of their position on the issue, the problem of HIV transmission through unsafe medical practices is significant enough to warrant fresh attention, according to the Monitor. Holly Burkhalter, policy director for Physicians for Human Rights, said that whether the proportion of HIV-positive Africans who became infected through unsafe medical practices is 2.5% or 33%, even one infection is too many. "It's the clearest example of substandard health care being tolerated for the poor that rich countries would never tolerate in their own hospitals and clinics," she said (Christian Science Monitor, 10/2).