Comment:

The Missing Link? “The Spread of HIV/AIDS in Africa through Unsafe Medical Care".

By John Kiwanuka Ssemakula (MD, MPH), October 22, 2002

The article entitled “The Spread of HIV/AIDS in Africa through Unsafe Medical Care" implies 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 underestimated.

And judging by the flurry of responses this article has generated, it seems to have struck a chord with many health professionals in Africa and around the world. Not only by the provocative questions it asks, but also for generating a new angle to approaching the HIV/AIDS problem.

Could this be the missing link that could explain the rapid spread of HIV/AIDS in Africa when compared to other parts of the world?

In making their case, the authors made the very important observation that  “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. “  In fact studies had found rates of partner change in Europe were up to 10 times higher than in equivalent African populations.

One of the more controversial and acrimonious areas of debate, from the beginning of the HIV/AIDS epidemic has been around sexual behaviour in Africa. Many Africans resented the implication of being sexually rampant without care. But despite there not being much scientific evidence to support this view it is now commonly accepted that the high rates of sexual partner change in Africa were one of the main reasons for the rapid spread of HIV/AIDS. Many Africans would beg to differ.

But if Africans are not having anymore sex that anyone else in the world, why is HIV/AIDS spreading so fast. And what would this mean for all the prevention programmes that are based on behaviour change in sexual patterns has been one of the main weapons in preventing HIV/AIDS. How will one know if their efforts are working? There have been few if any baseline studies on behaviour in Africa (a significant oversight in my opinion) which means that we have no way of knowing the true impact of prevention programmes.

The implications of this finding if true are enormous. It will have a considerable impact on the way the HIV/AIDS epidemic is being tackled in the future and I commend the authors for highlighting this very important point.

I like many other scientists have long wondered what could explain the rapid and aggressive spread of HIV/AIDS in Africa other than sexual transmission. I have always had a nagging suspicion that there was something not being considered, but did not have the ability to put any hypotheses to the test.

However recently I have come to the conclusion that two other factors need to be considered in the spread oh HIV/AIDS:

1.       Health systems (or lack of) are a possible significant factor in the transmission of HIV.

2.       The other factor is of course Conflict which was a significant factor in spreading AIDS in Uganda and Ethiopia.

The two are deadly combination. Conflict leads to the disruption and breakdown of health systems, and of course injuries, disease, refugees, immunization campaigns etc. One can of course see how such conditions where with lack of health services, with few health personnel and the pressure to ensure disease outbreaks do not occur, the need to treat wounded or sick people less than perfect sterilization techniques may be used. And the re-use of needles and syringes is a very common affair throughout Africa.

The evidence of the relation between countries / regions that have experienced conflict and then  subsequently seen huge increases in HIV infections a decade later is quite compelling.  In this regard the news that is coming out of West Africa, where civil war has raged in Sierra Leone, Liberia and more recently in Ivory Coast  is quite disturbing. It is now thought that Nigeria will be the next epicenter of a massive increase in HIV/AIDS infections.

For a doctor it is uncomfortable feeling to consider that in attempting to help save lives and alleviate suffering you could be contributing to the problem. But this is a possibility that must be faced. There is need for more large well funded comprehensive studies in looking at risks for HIV transmission through health care in Africa.

More reading

War and Epidemics

HIV infections in sub-Sahara Africa not explained by sexual or vertical transmission

The injection century: massive unsterile injections and the emergence of human pathogens