20 February 2003
healthcare "drives spread of African HIV"
Since the 1980s most experts have assumed that heterosexual
sex transmitted 90% of HIV in Africa. In the March International
Journal of STD and AIDS, an international team
of HIV specialists presents groundbreaking evidence
to challenge this consensus, with "profound implications"
for public health in Africa.
a series of articles, Dr David Gisselquist, Mr John
Potterat and colleagues argue that the spread of HIV
infections in Africa is closely linked to medical care.
In their unique study of existing data from across the
continent they estimate that only about a third of HIV
infections are sexually transmitted. Their evidence
suggests that "health care exposures caused more HIV
than sexual transmission", with contaminated medical
injections being the biggest risk.
HIV and STDs: According
to the authors' data, African HIV did not follow the
pattern of sexually transmitted disease (STD). In
Zimbabwe in the 1990s HIV increased by 12% a year,
while overall STDs declined by 25% and condom use
actually increased among high-risk groups.
rate: HIV spread very fast in many countries in
Africa. For the increase to have been all via heterosexual
sex, the study claims, it would have to be as easy
to get HIV from sex as from a blood transfusion. In
fact, HIV is much more difficult than most STDs to
transmit via penile-vaginal sex.
sex? Several general behaviour surveys suggest
that sexual activity in Africa is not much different
from that in North America and Europe. In fact, places
with the highest level of risky sexual behaviour,
such as Yaounde in Cameroon, have low and stable rates
of HIV infection. "Information…from the general population
shows most HIV in sexually less active adults" .
Did medical care spread HIV?
Children and injections:
Many studies report young children infected with HIV
with mothers who are not infected. One study in Kinshasa
kept track of the injections given to infants under
two. In one study, nearly 40% of HIV+ infants had
mothers who tested negative. These children averaged
44 injections in their lifetimes compared with only
23 for uninfected children.
Good access to medical care: Countries like
Zimbabwe, with the best access to medical care, have
the highest rates of HIV transmission. "High rates
[of HIV] in South Africa have paralleled aggressive
efforts to deliver health care to rural populations".
to be rich: Most STDs are associated with being
poor and uneducated. HIV in Africa is associated with
urban living, having a good education, and having
a higher income. In one hospital in 1984, the rate
of HIV in the senior administrators was 9.2%, compared
with the average employee rate of 6.4%.
"People often see what they wish to see"
authors suggest several reasons why evidence has been
ignored until now, including 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.
conclude: "a growing body of evidence points to unsafe
injections and other medical exposures to contaminated
blood" as an explanation for the majority of the spread
of the epidemic. "This finding has major ramifications
for current and future HIV control programmes in Africa"