Across sub-Saharan Africa, governments have not investigated unexplained HIV infections (not from sex or mother-to-child). If you know of one or more unexplained infections in your community, you might be at risk to get HIV when you go for health care, manicure, or other skin-piercing procedure. Because governments have not investigated, it’s up to people at risk to start their own informal investigations — asking people in the community if they know of more unexplained infections, and asking if they have any ideas about where doctors or others might be giving skin-piercing procedures with unsterile instruments. Governments will follow and help if people lead.
Failing their duty, government health experts and foreign experts and researchers have ignored evidence of HIV infections from unsafe healthcare. Here’s an example from one of the world’s worst HIV epidemics — in uMkhanyakude district, KwaZulu-Natal Province, South Africa.
In 2019 a random sample of adults in a large mostly rural study area in uMkhanyakude district found 67.5% of women aged 30-40 years to be HIV-positive (see page e972 in reference 5, below). How could so many be infected? For almost two decades, health experts have been surveying and studying people in the district — without ever bothering to investigate unexplained infections, without finding and stopping their source, and without warning people at risk.
Why have health experts been so negligent and careless about public health? Dense, heartless, some other excuse?
In August 2021, I submitted the following short account of evidence of bloodborne HIV transmission in the study area as a letter to the Proceeding of the National Academy of Science. The editor rejected it without explanation.
Submitted and rejected letter: HIV-1 incidence patterns in KwaZulu-Natal
Dr Akullian and co-authors report large reductions in HIV incidence, especially for young men and women, during 2012-19 in the Africa Health Research Institute’s surveillance area in KwaZulu-Natal, South Africa. Even so, incidence remained high: in 2019, the highest estimated age-specific incidence was circa 4.4% per year for women and circa 2.0% per year for men (see Figure 4C in ).
Although changes in HIV incidence are clear, the reasons for those changes are less well established. Authors ignore the possibility – hypothesis – that non-sexual transmission through skin-piercing procedures in health care and cosmetic services might be making a substantial contribution to incidence in the study area. In ignoring this hypothesis, authors disregard evidence from the study area, including:
* Unexplained infections: During 2004-15, adults and adolescents who claimed to be virgins accounted for 189 (8%) of 2,367 recognized incident infections (Table 1 in ).
* A cluster of 63 HIV with closely related sequences: Sequence analyses dated the cluster’s most recent common ancestor to June 2013; within 18 months to November 2014, infections from this common ancestor had reached 63 persons (slide 10 in ). The speed of transmission required to explain this cluster has been seen in nosocomial outbreaks (e.g., in Cambodia). Moreover, evidence from the study area suggests sexual partner change made little or no contribution to the cluster: only 43 (1.8%) of 2,367 adults with new infections in the study area during 2004-15 reported more than one partner in the previous year (Table 1 in ).
* Incidence too high to be explained by sex: The estimated circa 4.4% per year age-specific peak incidence rate in women in 2019 is greater than could be expected based the estimated percentage of their partners with unsuppressed viral loads: in 2019 <20% of men aged 30-39 years and lower percentages in other cohorts had unsuppressed viral loads (Figure 3A in ). In two large studies in Africa that included discordant couples in which many if not most wives did not know their husbands were infected, wives got HIV at rates of 10.5-12 per 100 person-years[6,7]. If women in the study area with sexual exposure to HIV got infected at such rates, one would expect circa 2% incidence per year, far less than peak age-specific incidence. This estimate ignores mitigating factors, such as concordant positive partnerships and condom use (during 2012-17, averages of more than 60% of women and 70% of men reporting condom use).
It is not possible to explain the above evidence from the study area without the hypothesis that bloodborne transmission is important. Alternately, one could hypothesize that evidence is wrong, and explain how and why that could be so. Researchers’ failure to respect – accept or reject – evidence pointing to bloodborne transmission parallels public health agencies’ failure to investigate unexplained infections: identifying sites with skin-piercing procedures, testing others attending such sites to find more victims, and thereby finding and stopping sources of bloodborne transmission.
1. A. Akullian et al. Large age shifts in HIV-1 incidence patterns in KwaZulu-Natal, South Africa. PNAS 118: e2013164118 (2021). [Available at: https://www.pnas.org/content/118/28/e2013164118, accessed 8 September 2021.]
2. A. Akullian et al. Sexual partnership age pairings and risk of HIV acquisition in rural South Africa. AIDS 31: 1755-1764 (2017). [Available at: https://pubmed.ncbi.nlm.nih.gov/28590328/, accessed 8 September 2021.]
3. C. Coltart et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Conference on Retroviruses and Opportunistic Infections, Boston, 4-7 March 2018. Abstract 47LB and oral abstract (2018). [Available at: http://www.croiwebcasts.org/console/player/37090?mediaType=slideVideo&, accessed 8 September 2021.]
4. F. Rouet et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin. Infect. Dis. 66, 1733-1741 (2018). [Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963970/pdf/cix1071.pdf, accessed 8 September 2021.]
5. E. B. Wong et al. Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study. Lancet Glob. Health 9, e967–76 (2021). [Available at: https://www.thelancet.com/action/showPdf?pii=S2214-109X%2821%2900176-5, accessed 8 September 2021.]
6. T. C. Quinn et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N. Engl. J. Med. 342, 921-929 (2000). [Available at: https://pubmed.ncbi.nlm.nih.gov/10738050/, accessed 8 September 2021.]
7. L. M. Carpenter et al. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 13, 1083-1089 (1999).
8. A. Vandormael et al., Declines in HIV incidence among men and women in a South African population-based cohort. Nat. Commun. 10, 5482 (2019). [Available at: https://www.nature.com/articles/s41467-019-13473-y, accessed 8 September 2021.]