UNIVERSITY OF PENNSYLVANIA - AFRICAN STUDIES CENTER
Africa: HIV/AIDS through Unsafe Medical Care Date distributed (ymd): 021008 Document reposted by Africa Action
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Region: Continent-Wide Issue Areas: +economy/development+ +health+
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 conclusion of the authors is important, as it challenges conventional wisdom on the relative importance of differernt means of transmission of HIV/AIDS. It is preceded by a brief non-technical summary by Africa 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."
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 citation and excerpts from article below)
The arguments in this article imply that Africa's HIV/AIDS crisis may be fueled as much or more by unsafe medical practices as by unsafe sex. Briefly, the authors say that the evidence available from an exhaustive review of research does not support the standard assumption that over 90% of HIV/AIDS in African adults is from heterosexual intercourse. 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, transfusions, and other contact with infected blood, is being grossly underestimated.
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 behavior accounts for only about a third of HIV infections, which suggests a very large role for unsafe health care in Africa's HIV epidemic. The implications: while safe sex is vital, measures to provide safe blood supplies, prevent reuse of unsafe needles, and address related issues of medical safety, are just as urgent.
International efforts to address these issues do exist, but are woefully underfunded. See http://www.who.int/bct http://safebloodforafrica.org and 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 redcctions
in spending on healthcare delivery, as Africa Action
has noted in earlier publications (see "Hazardous
to Health" at
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
HIV infections in sub-Sahara Africa not explained by sexual or vertical transmission
by David Gisselquist, PhD, independent consultant; Richard Rothenberg, 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 College of Medicine, NYC, USA
Correspondence and reprint requests to: David Gisselquist 29 West Governor Road Hershey, Pennsylvania 17033 USA; Email: firstname.lastname@example.org
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 associated 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 research is warranted to clarify risks for HIV transmission through health care.
Within two years after the first AIDS cases were described in homosexual 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 November 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 partners are at greater risk of acquiring AIDS is unknown " Meeting participants considered that "injections with unsterile needles and syringes may play a role " WHO's 1983 recommendations focused on sterilization of medical equipment, blood safety, and MSMs.
During 1983-88, researchers in Africa found high rates of HIV prevalence 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 acquired 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 patients 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 infections and that iatrogenic transmission is minimal. Many facts do not fit well.
Divergent epidemic trajectories.
Differences in sexual behavior across countries do not explain differences 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 declining during the 1990s. In others, such as South Africa and Botswana, 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 Africa.
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 characteristically 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 heterosexual 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 example, 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 inpatient 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 postpartum periods.
Studies from seven African countries over the last 15 years show rates of HIV incidence during antenatal and/or postpartum periods exceeding 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% observed by Semmelweis during 1841-46 in the First Clinic at the University 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 Malawi, 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 delivery.
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 population 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 sufficient 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)
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 hypotheses. There may, for example, be co-factors for sexual transmission not yet identified that are particularly influential during pregnancy or for young women. However, an accumulating body of evidence from Africa and other countries suggests that iatrogenic transmission 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 subcutaneous or intramuscular injections of infected patients; ...
An early prospective study among health care workers estimated the probability of seroconversion after work-related percutaneous exposure 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) ... Because 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 proportion of injections that were unsafe was greater than 50%. Despite the lack of systematic data collection noted by the authors, these findings 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 transmission 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 established 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 during 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 contracted HIV,(104, 105) and thousands of paid plasma donors in China may have been iatrogenically infected.(106) Smaller iatrogenic outbreaks have been reported among patients and plasma donors in other countries.
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 vanished 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. Fortunately, 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 represent a possibly major route of HIV transmission in countries with high HIV prevalence, the current tenets on which HIV prevention programs in Africa are based need reassessment. Though promotion of safe sexual practices remains a priority, new interventions may be required to minimize risk from iatrogenic transmission.
Message-Id: <200210082319.g98NJHT30776@marduk.africapolicy.org> Date: Tue, 8 Oct 2002 19:22:35 -0500 Subject: Africa: HIV/AIDS through Unsafe Medical Care
Editor: Ali B. Ali-Dinar
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