Spread of AIDS in Africa driven by poor medical practice, report says

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Spread of AIDS in Africa driven by poor medical practice, report says

Owen Dyer London

The spread of AIDS in Africa is driven not by unsafe sex but by unsafe medical practice, according to research published last week.

The research, which analysed data on new infections collected up to 1988, concludes that no basis exists for the widespread belief that sexual transmission is responsible for over 90% of new cases. Instead, the authors say, use of dirty needles by public health services was the main cause of transmission in the study period, with sexual transmission accounting for just 30% of infections.

In three articles, lead authors David Gisselquist, a private consultant anthropologist from Pennsylvania, and Dr John Potterat, an infectious diseases specialist from Colorado, point out numerous anomalies in the relation between risky sexual behaviour and prevalence of HIV (International Journal of STD & AIDS 2003;14:144-147, 148-61, 162-73)

In one study cited by the authors, Yaounde in Cameroon had a high level of risky behavioural markers yet a low and stable prevalence of HIV. Ndola in Zambia had the smallest proportion of both men and women who reported having had sex in the previous 12 months with someone who was not their spouse, yet it experienced a rapid rise in HIV.

Another apparent inconsistency in the sexual transmission model, says the group, is the continued reporting of HIV infection in the young children of seronegative mothers. A South African study found HIV in 6% of children aged 2 to 14 years, a figure too high to explain by maternal transmission alone (www.hsrc.ac.za/research/npa/SAHA/news/20021205Keynote.html). Another study found that HIV positive children had received more injections than uninfected children (Lancet 1986;ii:1103-4).

The authors point to the exceptionally rapid spread of the disease in countries with widespread health services, such as South Africa and Zimbabwe. In Zimbabwe in the 1990s, HIV infections increased by 12% a year whereas other sexually transmitted disease were declining by 25%.

The research has been greeted frostily by other experts in the field, who say it could drive patients away from needed health care and send the message that unprotected sex is not dangerous. Dr Cate Hankins of UNAIDS said: "I’m sure they mean well, but I don’t think they’ve thought out the public health implications of what they’re saying.

"All our evidence suggests that dirty needles account for about 5% of HIV transmission in the developing world. I don’t think they’ve brought anything new to discredit that. However, we’re going to hold a consultation and review the evidence." She said that recall bias could account for many of the discrepancies noted in the study.

Professor Michael Adler of University College London Medical School said: "It’s true there was a problem with infected needles in the 1980s, but it was nowhere near as big a factor as they suggest. If that many needles were dirty, we’d be seeing far higher rates of hepatitis than we are, because hepatitis is much more easily transmitted by injection than HIV."

The three articles are available at www.rsm.ac.uk/new/pr126.htm

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