Bloodborne HIV: Don't Get Stuck!

In December 2022, eSwatini’s Ministry of Health published results from a 2021 HIV survey.[1] Although the report does not say so, it shows how to stop the country’s HIV epidemic.

Most women’s infections not from sex

In 2021, women aged 15-49 years were getting HIV at the rate of 1.45% per year. Considering how many men were infected (18.7%) and how many had suppressed viral loads (86.1%), sex explains less than 0.3% of women getting HIV in a year. Hence, most women’s infections — >1.15% out of 1.45% — likely came from blood exposures during health care or cosmetic services, not sex.

Here’s how 2021 survey data show eSwatini women get HIV from sex at <0.3%/year:

• From the survey 18.7% of men aged 15 and older were HIV-positive of which 86.1% had suppressed viral loads and were no threat to infect anyone through sex. [1]
• Hence, only 2.6% (= 13.9% x 18.7%) of men were threats to infect their sex partners (18.7% were HIV-positive, but only 13.9% (= 1-86.1%)  of them had unsuppressed viral loads).
• HIV-positive men with unsuppressed viral loads could be expected to infect 11% of steady sex partners in a year (this 11%/year rate comes from 5 studies that followed men and women in Africa who did not know they were infected; reference[2] summarizes evidence from 5 studies[3-7]).
• Hence, if 2.6% of HIV-positive men with unsuppressed HIV had regular sex with HIV-negative women, men could be expected to infect 0.29% of women in a year (= 2.6% x 11%/year).
• BUT 0.29%/year getting HIV from sex is an overestimate, since many HIV-positive men are celibate during any given year (>10% in a recent survey[8], or have partners who are already HIV-positive[9]; and/or use condoms when they don’t know the HIV status of partners.[8]

Finding and stopping bloodborne transmission

The beginning of the end of eSwatini’s HIV nightmare arrives as soon as people – workers, teachers, farmers, clergy, etc – recognize one or more unexplained HIV infections in their community, and for their own protection demand that government investigates. Investigations test others attending suspected source facilities, find more infected, and find specific facilities and procedures that transmitted HIV. Around the world, such investigations have uncovered local outbreaks with 100s to 1,000s of infections from medical procedures. The biggest was in China during 1990-95, with an estimated 100,000 infected when they sold blood and plasma.[2]

References

1. Ministry of Health, eSwatini. Population-based HIV impact assessment: summary sheet. New York: Columbia University, 2022. Available at: https://phia.icap.columbia.edu/wp-content/uploads/2022/12/53059_14_SHIMS3_Summary-sheet-Web.pdf (accessed 29 December 2022).

2. Gisselquist D. Stopping Bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available at: https://sites.google.com/site/davidgisselquist/stoppingbloodbornehiv (accessed 29 December 2022).

3. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342: 921-929. Available at: https://pubmed.ncbi.nlm.nih.gov/10738050/ (accessed 30 December 2022).

4. Carpenter LM, Kamali A, Ruberantwari A, et al. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999; 13: 1083-1089. Abstract only available at: https://pubmed.ncbi.nlm.nih.gov/10397539/ (accessed 30 December 2022).

5. Senkoro KP, Boerma JT, Klokke AH, et al. HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991 through 1996. J Acquir Immune Defic Syndr 2000; 23: 194-202. Abstract only available at: https://pubmed.ncbi.nlm.nih.gov/10737435/ (accessed 30 December 2022).

6. Hugonnet S, Mosha F, Todd J, et al. Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr 2002; 30: 73- 80. Abstract only available at:  https://pubmed.ncbi.nlm.nih.gov/12048366/ (accessed 30 December 2022).

7. Serwadda D, Gray RH, Wawer MJ, et al. The social dynamics of HIV transmission as reflected through discordant couples in rural Uganda. AIDS 1995; 9: 745-750. Abstract only available at: https://pubmed.ncbi.nlm.nih.gov/7546420/ (accessed 30 December 2022).

8. Ministry of Health, Swaziland. Swaziland HIV incidence measurement survey 2 (SHIMS 2) 2016-17. New York: Columbia, 2019. Available at: https://phia.icap.columbia.edu/wp-content/uploads/2020/02/SHIMS2_Final-Report_05.03.2019_forWEB.pdf (accessed 29 December 2022).

9. Central Statistical Office, Swaziland. Swaziland Demographic and Health Survey 2006-07. Calverton (MD): Macro International; 2008. Available at:  https://dhsprogram.com/publications/publication-fr202-dhs-final-reports.cfm (accessed 29 December 2022).