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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

HIV/AIDS through Unsafe Medical Care
- Africa Action

An article in the International Journal of STDs and AIDS (Oct 2002) -"HIV
infections in sub-Sahara Africa not explained by sexual or vertical
transmission," by David Gisselquist, Richard Rothenberg, John Potterat, and
Ernest Drucker - was summarized by the APIC list, and has elicited an
interesting discussion and debate on the AFRO-NETS forum. We produce
excerpts from the APIC posting below

The full article is available (for a fee) on the journal website


Africa: HIV/AIDS through Unsafe Medical Care
Africa Policy Electronic Distribution List, Africa Action

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 different 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:

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
fuelled 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 under-estimated.

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

International efforts to address these issues do exist, but are woe-
fully underfunded. See:

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 reductions in spending on healthcare delivery, as
Africa Action has noted in earlier publications (see "Hazardous to Health").

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


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 nontrivial
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,

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 fuelling 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. Whilen 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

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

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 (Table1).(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

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

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

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.

Africa Action