A recent double-barreled smoking gun calls attention to mistakes that fuel Africa’s HIV/AIDS epidemics. The first smoking barrel is the discovery of an HIV outbreak in South Africa which is best explained by bloodborne transmission during health care. The second smoking barrel is the subsequent silence by public health and HIV/AIDS experts and officials about the likelihood that unsafe health care caused the outbreak. (A “smoking gun” is “an object or fact that serves as conclusive evidence of a crime or similar act…”)
First smoking barrel: HIV outbreak in Kwazulu-Natal, 2013-14
South Africa has one of the world’s most intense HIV epidemics with more than 20% of adults infected. Things are even worse in some places: for example, in a large mostly rural study area in KwaZulu-Natal province more than 60% of women aged 30-49 years were HIV-positive in 2016.
In 2010-14, researchers collected HIV from a random sample of adults in the KwaZulu-Natal study area mentioned in the previous paragraph. The team then sequenced 1,376 HIV samples (i.e., determined the order of HIV’s constituent parts). Because HIV changes over time, similar sequences from two or more people suggest recent and close transmission linkages. Among the 1,376 sequences, the study team found a cluster of 63 very similar HIV. The study team estimated that HIV from one person in June 2013 had somehow reached and infected 63 people within 17 months through November 2014.
The cluster reported from the study area is similar to clusters that governments outside sub-Sahara Africa have investigated and traced to unsafe health care. For example, the diagram linking 63 infections in KwaZulu-Natal (see slide 10 in reference ) is similar to diagrams linking HIV sequences from outbreaks in Libya in 1995-99 and in Cambodia in 2013-14.[6,7]
Because the 1,376 HIV came from a random sample of an estimated 9% of HIV-positive adults in the study area, the observed cluster of 63 infections may well be 9% of a much larger cluster in the study area. Moreover, because many of the 63 HIV came from a town on the border of the study area, the cluster likely extends outside the area; and transmission appeared to be ongoing when the study stopped collecting HIV samples in 2014.
Because it is almost impossible for such an outbreak to come from anything other than bloodborne transmission, the government of South Africa could protect public health by investigating to find and fix whatever caused it: asking people in the cluster what skin-piercing procedures they received and where during 2013-14, and then inviting others who visited suspected facilities to come for HIV tests. From 1986, at least 11 governments outside sub-Saharan Africa have investigated unexplained HIV infections to find and fix health care procedures that had caused large HIV outbreaks, infecting more than a hundred to as many as 50,000 people in China.[8,9]
The study that reported this KwaZulu-Natal outbreak suggested it might be from sex, but provides no information about sexual risks for anyone in the cluster. In any case, the possibility that sex could transmit HIV from 1 to 63 infections (much less hundreds) in 17 months is vanishingly small, considering:
- Even between spouses who are unaware one spouse is infected, it takes on average years for one to infect the other. In a 2016 national survey in South Africa fewer than half of men and women with HIV-positive spouses were themselves infected.
- According to self-reported sexual behavior, having multiple partners had little to do with HIV transmission in the study area. Repeat surveys in the study area during 2004-15 identified 1,265 new HIV infections in adults with information on sexual behavior; only 43 (3.4%) of adults with new infections reported more than one sex partner in the previous year, while 189 (14.9%) said they were virgins (Table 1 in reference ).
- Widely quoted estimates of the risk to transmit HIV through penile-vaginal sex say transmission occurs in fewer than 1 in 1,000 coital acts.
Even if someone, nevertheless, wants to argue or believe that sex could somehow account for all infections in the cluster, bloodborne transmission during health care remains a possible explanation. That possibility challenges the government of South Africa to investigate to protect public health.
Second smoking barrel: Expert and official silence about the likelihood unsafe health care cased the outbreak
Researchers from the African Health Research Institute and the University College London, who collected HIV from the study area in 2010-14, subsequently sequenced HIV samples and discovered the cluster in 2017. They reported their discovery on 5 March 2018 at the Conference on Retroviruses and Opportunistic Infections (CROI) in Boston. Although the cluster suggests unsafe health care transmitted HIV:
- We have found no evidence government of South Africa has investigated to protect public health.
- During their 2018 presentation at CROI the research team did not acknowledge the possibility that unsafe health care caused the outbreak, and none of the discussants even mentioned such risks.
- To the best of our knowledge, as we are writing this more than two years after the cluster was reported in 2018, no expert in HIV sequencing and no official in any international or foreign health organization or agency has publically acknowledged the possibility the cluster comes from unsafe health care.
Considering the many experts knowledgeable about sequencing and about Africa’s HIV epidemics, the fact that no one has said the obvious – that the cluster likely (or at least possibly) comes from unsafe health care – is strong evidence that people are choosing to keep silent. That in turn suggests they are aware of pressures not to say what is obvious. (The only exceptions to this silence are blogs on this website [search “KwaZulu-Natal] and several papers posted on SSRN by the authors of this blog, for example ).
Silence is strong circumstantial evidence – smoking gun evidence – that influential officials who control research funds and jobs for people working on HIV do not want them to talk about health care transmitting HIV in Africa. If anyone wants to challenge evidence-based suspicions that organizations such as the United States’ National Institutes of Health enforce such silence, the way forward is not to debate whether that is so but simply to break the silence – to acknowledge the cluster likely came from bloodborne transmission, and to recommend government of South Africa to investigate. Setting aside debate, the priority should be protecting patients and stopping Africa’s epidemics.
Perspective and context: 35 years of evidence and silence about HIV transmission during healthcare in Africa
Genetic evidence from the HIV cluster in KwaZulu-Natal, and subsequent silence about that evidence, are only the latest in decades of evidence and silence about health care transmitting HIV in Africa.[12-14] The double-barrelled smoking gun discussed in this note is remarkable because it involves experts in gene sequencing, a group that has only recently gotten more involved in HIV-related research in Africa and therefore has had no investment or involvement in decades of dismissive silence about unexplained and likely bloodborne HIV infections in Africa (such as HIV-infected children with HIV-negative mothers, HIV-positive virgin men and women).
Those who are silent are not explaining why they are silent. But insofar as Africans are at risk, the reasons for experts’ and officials’ silence is not important. What is called for, to protect Africans at risk, is not to explain why experts and officials are not doing their jobs, but rather to get some investigations underway and to warn Africans about risks to get HIV from health care as long as those risks are not found and fixed.
- Gisselquist D, Collery S. Africa’s HIV epidemics: Evidence from a double-barreled smoking gun. Social Science Research Network, 1 May 2020. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3590251 (accessed 1 May 2020).
- Coltart CEM, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Oral abstract. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&&crd_fl=0&ssmsrq=1522772955419&ctms=5000&csmsrq=5001(accessed 7 March 2020).
- Smoking gun. Wikipedia, 5 March 2020, at: https://en.wikipedia.org/wiki/Smoking_gun
- ICF. South Africa Demographic and Health Survey 2016. Rockville (MD): ICF, 2019. Available at: https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf (accessed 1 May 2020).
- Vandormael A, Akullian A, Siedner M, de Oliveira T, Bärnighausen T, Tanser F. Declines in HIV incidence among men and women in a South African population-based cohort. Nature Comm 2019; 10: 5482. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889466/pdf/41467_2019_Article_13473.pdf (accessed 7 March 2020).
- de Oliveira D, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from Libyan outbreak. Nature 2006; vol 444: pp 836-837.
- Black A, Bedford T. Roka/HIV/bayesian_timetree: evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: https://bedford.io/projects/roka/HIV/bayesian_timetree/(accessed 15 November 2018).
- Gisselquist D. Points to Consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis and Abbey, 2008. Available at: https://sites.google.com/site/davidgisselquist/pointstoconsider (acccessed 1 May 2020).
- Gisselquist D, Collery S. Bloodborne HIV: don’t get stuck. no date. Available at: https://bloodbornehiv.com/cases-unexpected-hiv-infections/ (accessed 7 March 2020).
- Akullian A Bershteyn A, Klein D, Vandormael A, Barnighausen T, Tanser F. Sexual partnership age pairings and risk of HIV acquisition in rural South Africa. AIDS 2017; 31: 1755-1764. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508850/ (accessed 1 May 2020).
- Centers for Disease Control and Prevention (CDC) HIV risk reduction tool. Atlanta: CDC, no date. Available at: https://wwwn.cdc.gov/hivrisk/about_the_data.html (accessed 7 March 2020).
- Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161. Available at: http://www.cirp.org/library/disease/HIV/gisselquist1/gisselquist1.pdf (accessed 1 May 2020).
- Potterat JJ. Why Africa? the puzzle of intense HIV transmission in heterosexuals. In: Potterat J.J. Seeking the positives: a life spent on the cutting edge of public health. North Charleston (SC): Createspace, 2015. p. 175-229. Available at: https://www.researchgate.net/publication/311993589_Why_Africa_The_Puzzle_of_Intense_HIV_Transmission_in_Heterosexuals (accessed 1 May 2020).
- Fernando D. The AIDS pandemic: searching for a global response. J Assoc Nurses AIDS Care 2018; 29: 635-641. Abstract available at: https://www.sciencedirect.com/science/article/abs/pii/S105532901830133X?via%3Dihub (accessed 7 March 2020).