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."

+++++++++++++++++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 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
 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 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:
 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 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.

Introduction

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)

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 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.

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 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.