Bloodborne HIV: Don't Get Stuck!

Protect yourself from bloodborne HIV during healthcare and cosmetic services

Africans at risk when health experts ignore unexplained HIV infections

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.[1] 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 [1]).

            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 [2]).

            * 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 [3]). The speed of transmission required to explain this cluster has been seen in nosocomial outbreaks (e.g., in Cambodia[4]). 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 [2]).

            * 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 [5]). 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[8]).

            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:, 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:, 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:;, 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:, 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:, 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:, 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:, accessed 8 September 2021.]

Geologists can’t find sand in Saudi Arabia!

OK, that’s not so. Geologists know there’s sand in Saudi Arabia. But what about health experts not finding HIV infections from health care in Africa?

All the best evidence says blood exposures in health care and possibly also cosmetic services – not sex — have been driving Africa’s HIV epidemics all along. (Yes, this is a controversial statement; so here are details and references[1].) But just like geologists who don’t know there’s sand in Saudi Arabia, health experts have only rarely identified HIV infections from health care in Africa. And when they have found evidence pointing to HIV from health care, they have mostly ignored and/or denied that happened. For example:

  • A self-declared virgin is HIV-positive? Experts say she lied (administering a double stigma – she’s a liar and a slut).
  • Baby is infected but mother not? Experts can’t deny that, so they ignore it.

I post this blog on the 40th anniversary of the first report of AIDS on 5 June 1981.[2] As soon as AIDS cases were discovered in the US, doctors recognized similar cases in Africa. In the 40 years from 1981 to 2021, medical researchers could have found and stopped HIV transmission through hospitals and clinics in Africa. But that hasn’t happened. No government in sub-Sahara Africa has investigated any unexplained HIV infection to find others infected from the same clinics and to find and stop the risks. Just let it happen, in other words.

When HIV transmission through health care has been so common for so long, how can health experts miss it? To miss it, experts have to be either naturally incompetent (simply not up to the job) or professionally incompetent (keeping quiet so as to keep their jobs).

Such consistent and widespread incompetence requires bad international leadership – discouraging people from finding and/or talking about HIV from health care. WHO, UNAIDS, CDC, and leading US and European universities and journals have helped to organize and enforce deliberate incompetence. Too many people have accepted bad leadership. As a consequence, Africans have suffered tens of millions of unnecessary HIV infections.

Finally, to avoid misunderstanding: sex is a risk. But it’s a secondary risk – people who got HIV from unsafe health care can infect unsuspecting sex partners. So: test sex partners for HIV, because you can’t tell from their sexual behavior if they might be infected. But don’t just worry about sex – blood exposures may be your biggest risk.


1. See chapter 6 in: Gisselquist D. Stopping Bloodborne HIV: investigating unexplained infections. London: Adonis & Abbey, 2021. Available at:

2. Gottleib MS, Schanker HM, Fan PT, et al. Pneumocystis pneumonia – Los Angeles. Morb Mort Weekly Rep 1981; 30: 250-252. Available at: (accessed 5 June 2021).

Mistakes explain Africa’s HIV epidemics: Evidence from a double-barreled smoking gun

A recent double-barreled smoking gun calls attention to mistakes that fuel Africa’s HIV/AIDS epidemics.[1] The first smoking barrel is the discovery of an HIV outbreak in South Africa which is best explained by bloodborne transmission during health care.[2] 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…”[3])

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.[4] 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.[5]

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.[2]

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 [2]) 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.[4]
  • 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 [10]).
  • 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.[11]

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.[2] 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.[2]
  • 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 [1]).

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.


  1. Gisselquist D, Collery S. Africa’s HIV epidemics: Evidence from a double-barreled smoking gun. Social Science Research Network, 1 May 2020. Available at: (accessed 1 May 2020).
  2. 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: 7 March 2020).
  3. Smoking gun. Wikipedia, 5 March 2020, at:
  4. ICF. South Africa Demographic and Health Survey 2016. Rockville (MD): ICF, 2019. Available at: (accessed 1 May 2020).
  5. 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: (accessed 7 March 2020).
  6. de Oliveira D, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from Libyan outbreak. Nature 2006; vol 444: pp 836-837.
  7. Black A, Bedford T. Roka/HIV/bayesian_timetree: evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: 15 November 2018).
  8. Gisselquist D. Points to Consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis and Abbey, 2008. Available at: (acccessed 1 May 2020).
  9. Gisselquist D, Collery S. Bloodborne HIV: don’t get stuck. no date. Available at: (accessed 7 March 2020).
  10. 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: (accessed 1 May 2020).
  11. Centers for Disease Control and Prevention (CDC) HIV risk reduction tool. Atlanta: CDC, no date. Available at: (accessed 7 March 2020).
  12. 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: (accessed 1 May 2020).
  13. 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: (accessed 1 May 2020).
  14. Fernando D. The AIDS pandemic: searching for a global response. J Assoc Nurses AIDS Care 2018; 29: 635-641. Abstract available at: (accessed 7 March 2020).

Will women who got HIV during the ECHO trial sue for damages?

More than a dozen studies over decades found that women who used Depo for birth control were more likely to get HIV than women who didn’t use it. Despite that evidence, governments of the US and Sweden, the Bill and Melinda Gates Foundation, and the UN Population Fund arranged and funded the ECHO trial (Evidence for Contraceptive Options and HIV Outcomes).[1]

The ECHO trial randomly assigned more than 7,000 HIV-negative women in eSwatini, Kenya, South Africa, and Zambia to one of three birth control methods: Depo, an intrauterine device, or a hormone implant. During 2015-18, the ECHO trial followed and retested women to see who got HIV.

The trial was unethical: Before the ECHO trial began to enroll women in December 2015, three reviews of accumulated evidence (from 10-18 studies published during 1993-2014) had estimated that Depo use increased women’s risk to get HIV by 40-50%.[2,3,4] Hence, assigning research participants to Depo violated the Declaration of Helsinki’s admonition to “promote and safeguard the health, well-being and rights of patients, including those who are involved in medical research.”[5]

The principle here is “equipoise”: research can be justified in situations where so far we don’t know the answer. But, in this case, we already know the answer. Giving women Depo to watch them get HIV is like asking women to cross streets with their eyes closed to see if they are more likely to get hit by cars vs. women who keep their eyes open.

As for  intrauterine devices and implants (the other two birth control methods in the study), there is not enough information to say what if any impact they have on women’s HIV risk. Similarly, no one can say if monthly injections of NET-EN (norethisterone enanthate) effect women’s HIV risk. The ECHO trial could have been both ethical AND useful if it had tested those methods against a safe option.  And there is a safe option: According to a lot of research, both before and after the ECHO trial began, pills do not increase women’s risk for HIV.[3,6] Hence, the ECHO trial could have tested various birth control methods (but NOT Depo) against pills. Such a trial would satisfy The Declaration of Helsinki ethical guidelines[5]: “The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best proven intervention(s)..”

As it turned out, and as could have been expected, a lot of women got HIV during the ECHO trial — almost 4% per year for all methods. Women taking Depo got HIV a bit faster, at 4.2% per year. Such high rates likely include a lot of infections from bloodborne risks.

The ECHO trial had no problem finding people willing to do the dirty work – to implement unethical research – and no problem getting ethical approval. More than 750 people collaborated in ECHO research and committees at WHO and Columbia University approved it as ethical.[1]

ECHO trial results have been widely misinterpreted. A report of the trial in The New York Times, for example, said the results show Depo-Provera “does not raise HIV risk.” Because the trial did not compare Depo-Provera to pills, it does not support that statement.[7] Just nonsense!

Like many other studies in Africa, the study withholds collected information that is relevant to assess sexual and non-sexual risks. Encouragingly, the study tested partners for HIV (pp 305-6 in [1]), but the study does not say how many partners tested HIV-positive or how much having an HIV-positive partner increased a woman’s HIV risk. Huh, isn’t that relevant to understand what happened?

The study does not report if women who got HIV during follow-up intervals reported any sex acts during those intervals — with HIV-positive partners or with anyone else. Withholding relevant information also violates the Declaration of Helsinki (article 36: “Researchers have a duty to make publicly available the results of their research on human subjects and are accountable for the completeness and accuracy of their reports…”).[5]

Aside from not reporting all relevant collected information, by all accounts the study did not collect other relevant information. Like most other foreign-funded HIV research in Africa, the study ignored non-sexual risks.

How to stop these outrages? Appealing to courts may get better results than waiting for health care professionals to change. Recently, a US court allowed Guatemalans harmed during medical research to sue private US institutions in US courts.[8] Does this mean that any woman in the ECHO trial randomized to Depo-Provera who got HIV during the trial could sue private US institutions involved in the trial in US courts?


1. Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 2019; published online June 13. Available at:; supplementary appendix available at: (accessed 24 May 2022)

2. Ralph LR, McCoy SI, Shiu K, Padian N. Hormonal contraception use and women’s risk of HIV acquisition: a meta-analysis of observational studies. Lancet Infect Dis 2015; 15: 181-89. Available at: (accessed 24 May 2022).

3. Morrison CS, Chen PL, Kwok C, et al. Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis. PLoS Med 2015; 12: e1001778. Available at: (accessed 26 July 2019).

4. Brind J, Condly SJ, Mosher SW, et al. Risk of HIV infection in depo-medroxyprogesterone acetate (DMPA) users: a systematic review and meta-analysis. Issues in Law and Medicine 2015; 30: 129-138. Abstract available at: (accessed 5 March 2018). More results from this review are at: Depo-Provera and HIV. PRI, no date. Available at: (accessed 6 March 2018).

5. World Medical Association (WMA). WMA Declaration of Helsinki – ethical principles for medical research involving human subject, amended October 2013. Ferney-Voltaire, France: WMA, 2013. Available at: (accessed 24 May 2022).

6. Polis CB, Curtis KM, Hannaford PC, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016; 30: 2665–83. Available at: (accessed 26 July 2019).

7. McNeil DG. Depo-Provera, an injectable contraceptive, does not raise HIV risk. New York Times 13 June 2019. Available at: (accessed 27 July 2019).

8. Stempel J. Johns Hopkins, Bristol-Myers to face $1 billion syphilis infections suit. Reuters 4 January 2019. Available at: (accessed 26 July 2019).

Government of Pakistan protects patients. African governments don’t. Why not?

On 21 July 2019, at an international HIV/AIDS conference in Mexico, Farima Mir reported an ongoing investigation in Ratodero, Pakistan, that has found hundreds of children with HIV from healthcare[1]:

“At the end of April, 46 children in the city tested positive for HIV. And within 2 days, 14 more children were reported in nearby towns. The government mounted a response, screening around 32,000 people… Ultimately, over 770 of the 997 reported new infections were in young children, most from ages 2 to 5 years… Mir said that almost all children who tested positive for HIV had ‘repeated injections for any illness,’ meaning reused syringes were likely to blame.”

What happened in Pakistan echoes what has been found elsewhere, for example, Russia in 1988, Romania in 1989, Libya in 1998, etc (for more information about these and other HIV outbreaks from health care click on “outbreaks and unexpected infections” in the menu at the right of this page).

Almost surely there are many similar outbreaks of HIV from reused and unsterilized syringes, needles, razors, needles and tubes for infusions, and other health care instruments in African countries with the world’s worst HIV epidemics. But no government in sub-Saharan Africa has looked to find and stop HIV from unsafe health care! Whereas Government of Pakistan protects people by investigating unexpected HIV infections, governments of sub-Saharan Africa stick their heads in the sand. How many more people will get HIV from health care in Africa before governments investigate unexpected infections to find and stop the problem?


1. Walker M. ‘Man-Made Disasters’ Stymie Progress on Global HIV. Medpage Today 22 July 2019. Available at: (accessed 23 July 2019).

Let’s stop HIV in Africa. What are you waiting for?

Question for African governments: Why haven’t you investigated unexplained HIV infections?

Question for CDC, UNAIDS, WHO: How can you say you want health care to be safe in Africa, but then NOT challenge governments to investigate unexplained infections?

Questions for people living in African: Do you know anyone who is HIV-positive who denies sexual risks? Do you believe them? Have you heard of a child with HIV but with an HIV-negative mother? If they got HIV from health care, you and your loved ones are also at risk. When are you going to ask your government to investigate unexplained infections to find and stop any hospital or clinic that has been infecting patients?

Question for researchers: Why haven’t you tried to find out how people got HIV: trace and test partners: ask where people got skin-piercing treatments?

Question for anyone: Why do you accept racist, sexual fantasies to explain Africa’s HIV epidemics? Yes, sex is a personal risk for HIV, but what is different in Africa that could explain Africa’s terrible HIV epidemics is not sexual behavior but unreliably sterile injections, infusions, and other health care procedures.

Hundreds of children in Pakistan infected by HIV from health care; government investigates to protect children

Beginning end-April 2019, government of Pakistan has been investigating an outbreak of HIV from unsafe health care in Ratodero county. As part of the investigation, government set up camps to test people for HIV. As of 23 May, tests on 20,800 people in Ratodero found >608 to be infected, including >500 children.[1] Almost all HIV-infected children had HIV-negative mothers. 

According to a recent report[2]: “Adviser to the Prime Minister for Health Dr. Zafar Mirza has said that outbreak of HIV in Ratodero has not only shaken the country but entire world adding when he was in Geneva he was also asked about surfacing of HIV… He said root cause of large number of children must be detected… He said federal government along with UNICEF, WHO, UNAID, Aga Khan, Aga Khan University Hospital and other organizations is cooperating with the Sindh government in this connection and they will continue to coordinate till root cause is detected, he added.”

In sub-Saharan Africa, children get HIV from unsafe healthcare, but no government has investigated to protect them

Lots of HIV-positive children with HIV-negative mothers are reported in Africa, but unlike Pakistan, no government has investigated. Nor have WHO or UNAIDS advocated any investigation. Here are some of the many reports of HIV-positive children in Africa with HIV-negative mothers:

* Mozambique, 2015: A random sample national survey found 30 HIV-positive children aged 6-23 months; 10 (33%) of the 30 children had mothers who were HIV-negative.[3]

* Uganda, 2011: A random sample national survey tested adults and children aged 0-5 years for HIV. Based on reports from this survey,[4] an estimated 17% (12 of 70) HIV positive children had mothers who tested HIV-negative (click on “outbreaks and unexpected infections” and then “Uganda” country page).

* Mozambique, 2009: A random sample national survey in 2009 tested children as well as adults for HIV. The study found 63 HIV-positive children aged 0-11 years old, of which 18 (29%) had mothers who tested HIV-negative.[5,6]

* Swaziland, 2006-7: A random sample national survey tested 1,665 mother-child pairs with children aged 2-12 years. Fifty children were infected; 11 (22%) of their mothers tested HIV-negative.[7,8]

WHO’s double standard

WHO’s double standard goes back decades. For example, during 1990-93, WHO’s Global Programme on AIDS coordinated studies in four African countries – Kigali, Rwanda; Kampala, Uganda; Dar es Salaam, Tanzania; and Lusaka, Zambia – to test inpatient children and their mothers for HIV infection. Combining data from the four cities, 61 (1.1 percent) of 5,593 children aged 6-59 months were HIV-positive with HIV-negative mothers.[9] Only three children had been transfused. Although these infections suggested a lot of HIV transmission through unsafe healthcare, WHO, incredibly concluded ‘the risk of…patient-to-patient transmission of HIV among children in health care settings is low.’[10]

At least WHO in 2019 is acting to protect children in Pakistan from getting HIV from unsafe healthcare. Will this ongoing investigation lead WHO to change its long-standing policy of neglect in Africa?


1. Masood T. Situationer: dealing with HIV outbreak among children. Dawn 23 May 2019. Available at: (accessed 24 May 2019).

2. Dawoodpoto J. “HIV in Ratodero has not only shaken the country but entire world.“ Daily Times 24 May 2019. Available at: (accessed 24 May 2019).

3. page 231 in: Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), e ICF, 2015. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. Rockville, Maryland: ICF, 2018. Available at:

4. Table 8.13 in: Uganda Ministry of Health, and ICF International. Uganda AIDS Indicator Survey (UAIS) 2011. Calverton: ICF International, 2012. Available at: 6 December 2018).

5. pp. 177-181 in: INS, INE, and ICF Macro. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. Calverton, Maryland: ICF Macro, 2010. Available at: (accessed 19 January 2012).

6. Brewer D. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. Webmedcentral 2011, Article ID WMC002206. Available at: 19 January 2012).

7. CSO, eSwatini, and Macro Int. Swaziland Demographic and Health Survey 2006-07. Mbabane, Swaziland: CSO and Macro International, 2008. Available at: (accessed 8 November 2018).

8. Okinyi M, Brewer DD, Potterat JJ. Horizontally acquired HIV infection in Kenyan and Swazi children. Int J STD AIDS 2009; 20: 852-857. Abstract available at 27 October 2018); article available at: (accessed 15 October 2018).

9. Hitimana D, Luo-Mutti C, Madraa B, et al. ‘A multicentre matched case control study of possible nosocomial HIV-1 transmission in infants and children in developing countries’, 9thInt Conf AIDS, Berlin 6-11 June 1993. Abstract no. WS-C13-2.

10. Global Programme on AIDS. 1992-1993 Progress Report, Global Programme on AIDS. Geneva: WHO, 1993. p. 85.

Addressing a running sore: HIV in South Africa


South Africa, where doctors achieved the first human heart transplant and one of the wealthiest countries in Africa, has a terrible HIV epidemic. In 2015, an estimated 30.8% of pregnant women were HIV-positive at their first antenatal visit, with more pregnant women infected in parts of the country: for example, 44.5% in KwaZulu-Natal province and 48.4% in Zululand district of that province.[1] Even more adults were infected in some age cohorts and regions: for example, in a 2014 survey of a study population in uMungundlovu district, KwaZulu-Natal, more than 66% of women aged 30-39 years were HIV-positive as were 59.6% of men aged 40-44 years.[2] Although South Africa has only 0.75% of the world’s population, a 2017 national survey estimated 7.9 million South Africans infected,[3] more than a fifth of the world’s total HIV infections.[4]

The South African government is doing a lot of what is required to respond to this epidemic with one glaring exception: the government has not investigated any unexpected and unexplained infections (i.e., not from sex, mother-to-child, or injection drug use) to find and stop blood-borne HIV transmission during health care and cosmetic services.

Doing things right: 90-90-90

In 2014, UNAIDS launched the 90-90-90 initiative, setting targets for testing and treatment to be achieved by 2020: 90% of people with HIV know they are infected, 90% who know are on antiretroviral therapy (ART), and 90% on ART have suppressed viral loads.[5]

Government of South Africa has made encouraging progress towards 90-90-90 targets. In a 2017 national survey, 84.9% of HIV-positive adults aged 15-64 years knew they were infected, 70.6% of those who knew were on ART, and 89.5% of people taking ART were virally suppressed. Putting these numbers together, 54% of HIV-positive adults were virally suppressed (54% = 84.9% x 70.6% x 89.5%).[6] The 90-90-90 targets are intended not only to reduce AIDS sickness and deaths but also to reduce HIV transmission. People with suppressed viral loads are not likely to transmit sexually because they have so little virus in semen or vaginal fluids.

Government of South Africa has also done well with prevention of mother-to-child transmission. As of 2017, more than 95% of pregnant women were tested for HIV and those found infected were given ART both to protect them and to prevent HIV transmission to their babies.[4] In 2016-17, less than 1% of HIV-positive mothers transmitted HIV to their babies before and during birth.[7]

Even before the 90-90-90 initiative, government of South Africa in 2010 began an HIV testing campaign, testing 13.3 million people over 18 months, finding 2 million with HIV, and putting 400,000 on treatment.[8] Also in 2010, government told providers to offer an HIV test to anyone seeking health care at a public facility.[9] To make testing easier, government in 2016 approved sale of self-testing kits through private pharmacies and other outlets.[10] These policies and programs support efforts to reach the testing target for 2020 – that 90% of people who are infected know it. More testing contributes to prevention by making it easier for people to know if their (potential) sex partner is HIV-positive, so they know to use condoms or otherwise protect themselves.

Doing things wrong: not investigating unexpected infections

With more testing, treatment, and other factors, the annual number of new HIV infections in South Africa fell 40% from 386,000 in 2010 to 231,000 in 2017.[3] Even so, South Africa’s HIV/AIDS disaster is reaching the next generation: in 2017 young women aged 15-24 years were getting HIV at the rate of 1.5% per year.[3]

The terrible scale of South Africa’s HIV epidemic is due in part to government not doing what it could to protect people. Over the years, public media and medical journals have recognized and reported unexpected HIV infections in South Africa. Nevertheless, as of early 2019, government has not investigated any unexpected infection by identifying suspected source facilities and then tracing and testing others treated at those facilities. For example, beginning in 1999, a group of doctors in Cape Town from time to time asked about and identified possible health care risks for more than 20 HIV-positive children with HIV-negative mothers.[11,12] But government did not subsequently trace and test others treated at suspected source facilities. Without tracing and testing to find others infected at the same facilities it is not possible to determine the extent of any outbreak or to find and fix the specific lapses in standard precautions responsible; and the public remains at risk.

Government of South Africa’s response to unexpected infections contrasts sharply with responses by governments outside sub-Saharan Africa. For example, in 1988 doctors in Elista, Russia (part of the USSR at the time), found and reported unexpected HIV infections in a hospitalized baby with an HIV-negative mother and a blood donor with no sexual risk. Government investigated, testing thousands, tracing transmission from one child directly and indirectly to 265 children in 13 hospitals, and ending the outbreak by August 1989.[13,14] From 1989 through 2014, nine other governments (Cambodia, China, India, Kazakhstan, Kyrgyzstan, Libya, Mexico, Romania, and Uzbekistan) investigated unexpected infections to uncover nosocomial (through health care) HIV outbreaks with more than 100 to more than 55,000 infections [15-17]). Many other governments have investigated unexpected infections to find smaller outbreaks.[16]

A lot of evidence suggests HIV transmission through skin-piercing procedures in health care, and possibly also during cosmetic services, have been and remain common in South Africa. Following paragraphs summarize selected evidence from later to earlier reports.

Incidence in children aged 2-14 years: The fifth South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2017, reported children aged 2-14 years acquired new HIV infections at the rate of 0.13% per year.[6]

Higher HIV prevalence in Black Africans than in other groups: The same 2017 national survey reported much higher HIV prevalence in Black Africans of all ages (16.6%) than in Whites (1.1%), Coloured (5.3%), or Indian/Asians (0.8%).[6] The survey gives no explanation for these differences in terms of sexual behavior. Male circumcision is not a factor: as of 2012, it was more common among Black African adults (52.4%) compared to Whites (23.3%), Coloured (26.4%), or Indian/Asians (33.5%).[18] There is, however, a big difference in where people get health care: in the second national HIV survey in 2005, 80% of Whites reported they usually get health care from private providers, while 80% of Black Africans reported they got most health care from public services.[19]

Unexplained infections in high school women: A 2011-2017 study in Mpumalanga province tested 2,533 high school women aged 13-20 years; 81 were HIV-positive, including 38 who reported never having vaginal or anal sex.[20] The study then followed and retested the women for 1-6 years during which 190 got HIV, including 44 who reported no lifetime sex.[21] At annual surveys during the first three years of follow-up an average of only 9% of women reported any sex without a condom in the previous three months[22]; and from what women reported about partners’ ages (less than 9% were aged over 24 years) less than 10% were HIV-positive.[22,23] Even if all women reporting unprotected sex in the previous three months had unprotected sex 104 times per year (or twice per week; an intended overestimate, considering most were in school), one could expect to see only 0.1% of women get HIV from sex each year, far less than observed incidence of 1.8% per year[22] (0.1% = 9% of women reporting unprotected sex in the previous three months x 104 sex acts per year x 10% of partners are HIV-positive x transmission efficiency of 1 per 1,000 coital acts; the next paragraph references this estimated transmission efficiency)

(This paper estimates transmission efficiencies of HIV through unprotected vaginal sex at 1 per 1,000 coital acts or 10% per year from an infected spouse based on the following references. The United States Centers for Disease Control and Prevention estimates transmission per unprotected coital act at 0.8 per 1,000 from men to women and 0.4 per 1,000 from women to men[24]. A widely cited estimate from a study in Uganda is 1.2 per 1,000 coital acts (with some condom use, which had no impact on estimated transmission efficiency).[25] Six studies in Africa followed discordant couples in which most partners were not aware of their infections or risks and/or did not use condoms; from these six studies both the mean and average rates of HIV incidence in initially HIV-negative partners were less than 10% per year.[26-31] Here and elsewhere I report rates of HIV incidence as percentages per year, a statistic more familiar for non-technical readers than the technical term, infections per 100 person-years.)

HIV-positive virgin men and women: In a 2014-15 survey among adults aged 15-49 years in uMgungundlovu district, KwaZulu-Natal, 11.2% of (self-reported) virgin women were HIV-positive as were 9.0% of virgin men.[2]

Higher incidence in young women than can be explained by sex: Repeated surveys of a study population in mKhanyakude district, KwaZulu-Natal, reported young women aged 15-24 years acquired new HIV infections at the rate of 5.9% per year (486 infections in 8,211 person-years) during 2011-15.[32] Such high incidence is difficult to reconcile with women’s limited sexual exposures to HIV, suggesting most infections come from risks other than sex. In the 2015 survey, 34% (847/2,467) of young women reported at least one coital act without condoms in the previous year,[32] and HIV prevalence was 10% among men who reported sex with a young woman in the past year.[33] Assuming women who reported unprotected sex in the past year averaged 104 unprotected coital acts per year (an intended over-estimate) and a transmission efficiency of 1 per 1,000 coital acts, sex explains incidence of only 0.4% per year, far less than the observed rate of 5.9% per year (0.4% = 34% of women with any unprotected sex in the past year x 104 coital acts per year x 10% of partners were HIV-positive x 0.001 transmissions per unprotected coital act[24,25]).

Cluster of 63 recent and linked infections: The African Health Research Institute found a cluster of 63 very similar HIV (similar sequences of amino acids) in blood collected during 2011-14 from 1,376 adults in a study population in uMkhanyakude district, KwaZulu-Natal. The Institute estimated HIV from one (unidentified) person in mid-2013 was somehow transmitted directly and indirectly over 18 months to 63 men and women.[34] Such fast transmission does not seem possible through sex, with transmission through vaginal sex requiring on average circa 1,000 coital acts; even for receptive anal sex an estimated average of 70 events are required for each transmission.[24] However, such rapid transmission is seen in nosocomial outbreaks; compare, for example, the phylogenetic tree of HIV genetic sequences from an outbreak in Cambodia[35] with the cluster of 63 HIV sequences from KwaZulu-Natal (slide 10 in [34]).

Unexplained infections in pregnant women: Four studies reported numbers of new HIV infections and rates of HIV incidence ranging from 10.7%-11.2% per year (or data to calculate these statistics[36]) in pregnant women during 2002-12. Women would not get HIV through sex at such rates unless all or almost all of their partners were infected. But during those years, less than 15% of adult men in South Africa were HIV-positive[4]; and many HIV-positive married men were married to women who were already infected.[37] The four studies are as follows: Wand and colleagues followed pregnant women in Durban during 2002-5, reporting data to calculate 81 incident infections in pregnant women and incidence of 10% per year[38]; Moodley and colleagues followed pregnant women in Mpumulanga, Eastern Cape, and Free State during 2006-7, observing 72 incident infections and incidence of 10.7% per year[39]; Kharsany and colleagues followed pregnant women in KwaZulu-Natal during 2007-8, observing four incident infections and calculating incidence of 11.2% per year[40]; and Dinh and colleagues reported 212 incident infections in a national sample of pregnant women and data to calculate incidence at 11% per year.[41]

HIV in high school virgin boys and girls: A 2012 survey of students in grades 8-12, averaging 15.8 years old, in KwaZulu-Natal reported 21 (55%) of 38 HIV-positive boys said they were virgins as did 56 (54%) of HIV-positive girls.[42]

HIV incidence in adults with no reported sex risks: The South Africa HIV Prevalence, Incidence, Behaviour and Communication Survey, 2005 (the second such national survey) reported HIV incidence of 1.5% per year in self-reported virgin adults, 2.4% per year in non-virgin adults who reported no sex in the previous year, and a similar 2.4% per year in adults who said they had been sexually active in the previous year.[43]

South Africa’s early epidemic doubles in 9-14 months: At the beginning of the HIV epidemic among Black South Africans in the late 1980s, the number of HIV-positive people doubled in about nine months[44]. During 1990-94, the doubling time for HIV prevalence in pregnant women throughout South Africa averaged 14 months (from 0.7% in 1990 to 7.6% in 1994).[45] The speed of transmission required for such rapid epidemic expansion is much faster can be explained by estimated rates of sexual transmission (1 per 1,000 coital acts or 10% per year between discordant couples[24-31]).

Fixing South Africa’s incomplete HIV prevention program: investigating unexplained infections

South Africa’s promotion of testing and treatment to reach 90-90-90 targets can be expected to slash sexual transmission. As targets are reached, more than 70% (~90% x 90% x 90%) of those infected will have suppressed viral loads and very little risk to transmit to a sexual partner. And with more testing, more people will know if partners are infected, so they will know to be careful.

But 90-90-90 may have less limited impact on blood-borne transmission. Based on outbreak investigations in other countries, blood-borne infections are often found in bunches. For example, HIV went from one in-patient baby to 265 children in 16 months in Russia,[14] from one to 418 infections in 3-4 years in Libya,[46] and from two to more than 200 infections in several years in Cambodia.[35] Large outbreaks characteristically come from facilities giving repeat treatments, where some people infected earlier get another procedure within weeks to month when they have primary infections and high viral loads, making their blood more dangerous and contributing to later transmissions.

The frequent bunching of blood-borne infections from specific facilities means that any identified unexpected HIV infection should be considered – until proven otherwise – to be one of many in an outbreak. When onward transmission occurs within several months, routine testing is not likely to find people with new blood-borne infections before they infect others through the outbreak. Moreover, even if someone tests HIV-positive with a very early infection, if the only risk anyone thinks about is sex, knowing he or she is infected would have no impact on their getting more skin-piercing procedures at the facility that is the source of the outbreak.

Educating health care workers – a continuing effort – has not stopped unexpected infections. Without outbreak investigations, no one knows the specific skin-piercing procedures and facilities responsible for unexpected infections, so there is no way to know where and how to focus efforts to repair dangerous procedures. Investigations in other countries have implicated a long list of health care procedures, including intra-muscular and intravenous injections, flushing intravenous lines, taking medicine from multi-dose vials, dental care, blood tests, blood and plasma donation, and others. Skin-piercing cosmetic procedures, such as tattooing, shaving, and manicures may also be involved.

Getting from no to yes: Officials in the government of South Africa have for decades consistently decided not to investigate unexpected infections. Increasing public awareness of unexpected infections could create public pressure for investigations. Libya and Cambodia provide examples of public pressure successfully pushing governments to investigate.

  • In Libya in August 1998, a magazine reported HIV infections in children traced to the El Fatah Hospital, Benghazi. The government’s initial response was to close the magazine. But parents did not take “no” for an answer. In November 1998 “a group of desperate fathers interrupted a medical conference Ghadafi was attending in Benghazi and appealed to him for help.”[47] Gaddafi ordered treatment for infected children and an investigation that offered HIV tests to all children treated at El Fatah Hospital in the previous year. The investigation found 418 children with HIV from healthcare.
  • In Roka, Cambodia, in November 2014, a 74-year-old man tested HIV-positive. Surprised, he sent his son-in-law and granddaughter for tests; both were infected. More villagers, alerted and worried, went for tests; many found they were infected. Acting on this information, government began an investigation in mid-December. The investigation reported 242 infections, attributing most if not all to skin-piercing procedures from a local private health care provider.[48,49]

With South Africa pursuing 90-90-90 targets, more people are getting tested. In the 2017 national HIV survey, 75.2% said they had ever been tested for HIV, and 66.8% had been tested within the past 12 months.[3] For many South Africans, an HIV-positive test comes as a surprise. In the previous 2012 survey 80% of adults considered themselves at low risk for HIV, giving reasons such as: “I use condoms”; “I abstain from sex”; “I am faithful to my partner.” But many self-assessed low risk adults were infected, accounting for 56% of adult HIV infections (calculated from data in Table 3.56 in [18]). As testing expands, more people are finding themselves with unexpected infections.

What happens next may well depend on whether people who have unexpected infections are able to get a respectful hearing from counselors, the media, churches, lawyers, support groups, non-government organizations, etc. To date, too few of those who manage or participate in public dialogue about HIV have been willing to believe people who report unexpected infections and to push government to mount the proper response to protect public health, i.e., to investigate, to look for outbreaks.

Making investigations work for public health: From a public health point of view, the priority for investigations is to determine the extent of the problem (to find all who were infected in each investigated outbreak) and to identify specific procedural lapses and facilities responsible. What might be ideal under such circumstances is for government to legislate to allow no-fault investigations along the lines of the post-apartheid Truth and Reconciliation Commission.

Attempting to punish or to collect compensation can create situations of conflict in which people who know what happened are motivated not to tell, investigators are pressured not to look, and blame and punishment fall on scapegoats. Open and thorough investigations educate and alert everyone – health care staff, cosmetic service providers, and the public – to be more aware of blood-borne risks. Punishing past mistakes is not necessary to improve health care safety; many health care staff will no doubt be mortified to learn that what they thought was safe may have infected patients. As for compensation, considering decades of inaction and inattention, it is not easy to identify anyone other than the government which both shares responsibility and has resources commensurate with whatever the problem might be. In any case, those who have been harmed already have free treatment.

Public trust in healthcare safety: Although officials have not explained why they have not investigated unexpected HIV infections, one reason may have been to maintain public trust in health care safety. Outbreak investigations that ask former patients at specific facilities to come for HIV tests challenge that trust by making the public aware of possible mistakes. But that is only a short term view of the matter. Acknowledging, investigating, and fixing problems builds trust in the long term.


No one has identified differences in sexual behavior that could explain much higher HIV prevalence in South Africa than in all non-African countries as well as in all but a few regional countries in Africa. One possible explanation is that lapses in health care safety have been driving South Africa’s epidemic. If that is so, then investigations of unexpected infections could lead to a dramatic drop in HIV transmission.

But even if blood-borne risks make only a limited contribution to South Africa’s epidemic, investigations protect public health. According to the World Medical Association’s Declaration of Lisbon on the Rights of the Patient, health care managers and providers have a responsibility to give patients “medical care of good quality” and “health education that will assist him/her in making informed choices about personal health and about the available health services.”[51] Without outbreak investigations, this is not possible.

Similarly, even if blood-borne risks make only a limited contribution to South Africa’s epidemic, investigations that recognize blood-borne transmission at any level undermine the stigmatizing belief that an HIV infection is a sign of sexual behavior.


1. National Department of Health (NDoH). The 2015 National Antenatal Sentinel HIV & Syphilis Survey, South Africa. Pretoria: NDoH, 2017.

2. Kharsany ABM, Cawood C, Khanyile D, et al. Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey. Lancet HIV 2018; 5: e 427-e437. Abstract available at: 23 October 2018).

3. Human Sciences Research Council (HSRC) Key Findings Presentation: The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communications Survey, 2017. Cape Town: HSRC, 2018. Available at: (accessed 30 January 2019).

4. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Geneva: UNAIDS, 2018. Available at: (accessed 5 January  2019).

5. UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. 2014. Available at: 19 October 2018).

6. HSRC. HIV Impact Assessment Summary: The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communications Survey, 2017. Cape Town: HSRC, 2018. Available at: (accessed 27 January 2019).

7. Goga A, Chirinda W, Ngandu NK. Closing the gaps to eliminate mother-to-child transmission of HIV (MTCT) in South Africa: Understanding MTCT case rates, factors that hinder the monitoring and attainment of targets, and potential game changers. S Afr Med J 2018; 108: S17-S24. Available at: (accessed 30 January 2019).

8. Burton R, Giddy J, Stinson K. Prevention of mother-to-child transmission in South Africa: an ever-changing landscape. Obstet Med 2015; 8: 5-12. Available at: (accessed 30 January 2019).

9. Pillay Y, White C, McCormick N. How times have changed – HIV and AIDS in South Africa in 2011. S Afr J Med 2012; 102: 77-78. Available at: (accessed 28 February 2019).

10. Venter F, Majam M, Jankelowitz L, et al. South African HIV self-testing policy and guidance considerations. S Afr J HIV Med 2017: 18, a775. Available at: (accessed 31 January 2019).

11. Hiemstra R, Rabie H, Schaaf HS, et al. Unexplained HIV-1 infections in children – documenting cases and assessing for possible risk factors. S Afr Med J 2004; 94: 188-193. Abstract available at: (accessed 10 December 2018).

12. Slogrove S, Rabie H, Cotton M. Non-vertical transmission of HIV in children: more evidence from the Western Cape, South Africa. Poster presented at the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention, July, 2011, Rome. Available at (search for Slogrove): (accessed 10 December 2018).

13. Belitsky V. Children infect mothers in AIDS outbreak at a Soviet hospital. Nature 1989; 337: 493. Available at: (accessed 14 October 2018).

14. Pokrovsky VV. Localization of nosocomial outbreak of HIV-infection in southern Russia in 1988-1989. 8th Int Conf AIDS. 19-24 July 1992; abstract no. PoC 4138. Available at:;view=fulltext (search for “pokrovsky” and find the 12th of 23 appearances; accessed 14 October 2018).

15. Ministry of Health, People’s Republic of China, UNAIDS, and WHO. 2005 update on the HIV/AIDS epidemic and response in China. Ministry of Health, People’s Republic of China, UNAIDS, and WHO. Geneva: UNAIDS, 2006. Available at: (accessed 12 February 2018).

16. Gisselquist P. Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis & Abbey, 2008. Available at: (accessed 30 November 2018).

17. Gisselquist D, Collery S. Unexpected HIV and outbreaks. Don’t Get Stuck with HIV [internet]. WordPress, ND. Available at: (accessed 29 November 2018).

18. Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence, Incidence, Behavioral and Communication Survey, 2012. Cape Town: HSRC Press, 2014. Available at: (accessed 5 February 2019).

19. Shisana O, Rehle T, Simbayi L, et al. South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2005. Cape Town: HSRC, 2005. Available at: (accessed 30 January 2019).

20. Pettifor A, MacPhail C, Selin A, et al. HPTN 068: a randomized control trial of a conditional cash transfer to reduce HIV infection in young women in South Africa – study design and baseline results. AIDS Behav 2016; 9: 1863-1882. Available at: (accessed 18 December 2018).

21. Stoner MCD, Nguyen N, Kilburn K, et al. Age-disparate partnerships and incident HIV infection in adolescent girls and young women in rural South Africa. AIDS 2019; 33: 83-91. Available at: (accessed 3 February 2019).

22. Pettifor A, MacPhail C, Hughes JP, et al. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial. Lancet Glob Health 2016; 4: e978-e988. Available at: (accessed 18 December 2018).

23. Gomez-Olive FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, et al. Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care 2013; 29: 1122-1128. Available at: (accessed 15 December 2018).

24. Centers for Disease Control and Prevention (CDC). HIV risk behaviors [internet]. Atlanta: CDC, 4 December 2015. Available at: (accessed 12 December 2018).

25. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: 1149-1153. Available at: (accessed 12 December 2018).

26. 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 available at: (accessed7 February 2019).

27. 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 available at: (accessed 7 February 2019).

28. Wawer MJ, Sewankambo NK, Berkley S, et al. Incidence of HIV-1 infection in a rural region of Uganda. BMJ 1994; 308: 171-3. Available at: (accessed 7 February 2019).

29. 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: 745-50. Available at: (accessed 7 February 2019).

30. Carpenter LM, Kamali A, Ruberantwari A, Malamba SS, Whitworth JAG. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999; 13: 1083-9. Available at: (accessed 7 February 2019).

31. 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: 921–9. Available at: (accessed 28 February 2019).

32. Chimbindi N, Mthiyane N, Birdthistle I, et al. Persistently high incidence of HIV and poor uptake in adolescent girls and young women in rural KwaZulu-Natal, South Africa prior to DREAMS. PLoS ONE 6 October 2016. Available at: (accessed 21 December 2018).

33. Doyle AM, Flowy S, Baisley K, et al. Who are the male sexual partners of adolescent girls and young women? Comparative analysis of population data in three settings prior to DREAMS roll-out. PLoS ONE, 28 September 2018. Available at: (accessed 21 December 2018).

34. Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions [internet]. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Abstract 47LB. Available at: 4 April 2018).

35. Black A, Bedford T. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak [internet]. Seattle: Bedford Lab, no date. Available at: 15 November 2018).

36. Gisselquist D. Missed signals: not investigating high HIV incidence in pregnant women [internet]. Amsterdam: Social Sciences Research Network, 17 April 2018. Available at: (accessed 6 February 2019).

37. National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and ICF. South Africa Demographic and Health Survey 2016. Pretoria, South Africa, and Rockville, Maryland, USA: NDoH, Stats SA, SAMRC, and ICF, 2019. Available at: (accessed 6 February 2019).

38. Wand H, Ramjee G. Combined impact of sexual risk behaviors for HIV seroconversion among women in Durban, South Africa: implications for prevention policy and planning. AIDS Behav 2011; 15: 479-486. Abstract available at: (accessed 28 February 2019).

39. Moodley D, Esterhuizen TM, Pather T, et al. High HIV incidence during pregnancy: compelling reason for repeat testing. AIDS 2009; 23: 1255-1259. Abstract available at: (accessed 28 February 2019).

40. Kharsany ABM, Hancock N, Frolich JA, et al. Screening for ‘window-period’ acute HIV infection among pregnant women in rural South Africa. HIV Med 2010; 11: 661-665. Available at: (accessed 28 February 2019).

41. Dinh T-H, Delaney KP, Goga A, et al. Impact of maternal HIV seroconversion during pregnancy on early mother to child transission of HIV (MTCT) measured at 4-8 weeks postpartum in South Africa 2011-2012: a national population-base survey. PLoS 2015; 10: e0125525. Available at: (accessed 25 October 2017).

42. Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmissions among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: (accessed 13 February 2018).

43. Rehle T, Shisana O, Pillay V, et al. National HIV incidence measures – new insights into the South African epidemic. So Afr Med J 2007; 97: 194-199. Available at: (accessed 6 February 2019).

44. Padayachee GN, Schall R. Short-term predictions of the prevalence of human iimmunodeficiency virus infection among the black population in South Africa. S Afr Med J 1990; 77: 329-323. Available at: (accessed 29 January 2019).

45. National Department of Health. The 2012 National Antenatal Sentinel HIV & Herpes Simplex Type-2 Prevalence Survey in South Africa. Pretoria: National Department of Health, 2012. Available at: (accessed 4 February 2019).

46. de Oliveira T, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from a Libyan outbreak, Nature 2006; 444: 836-837. Available at: (accessed 28 February 2019).

47. Abu-Nasr. AIDS scandal in Libya. CBS News. 20 September 2001. Available at: (accessed 29 November 2018).

48. Pisey H. More than 200 infected in HIV outbreak. The Cambodia Daily 29 December 2014. Available at: (accessed 29 November 2018).

49. Vun MC, Galang RR, Fujita M, et al. Cluster of HIV infections attributed to unsafe injections  – Cambodia December 1, 2014-February 28, 2015. Morbidity and Mortality Weekly Report 2016; 65: 142-145. Available at: 28 March 2016).

50. World Medical Association (WMA). Declaration of Lisbon on the rights of the patient. Ferney-Voltaire: WMA, 2015. Available at: (accessed 11 November 2018).


WHO’s early AIDS experts misdirected HIV prevention

Michael Merson, the second head of WHO’s Global Program on AIDS and co-author Steven Inrig describe WHO’s early AIDS response in The AIDS Pandemic: Searching for a Global Response.[1] Unfortunately, their otherwise excellent and detailed history ignores a tragic and continuing failure: the decision by WHO’s experts to accept an unknown  number of HIV infections from unsafe healthcare.

This misdirection has continued. Daniel Fernando reviews the confusion that led to this misdirection in a recent article[2]: “Already by 1985, WHO staff declared ‘Heterosexual promiscuity (large number of partners) is the most important risk factor among adult AIDS patients in Africa.’[quoted from page 9 in reference 3]…If iatrogenic transmissions had been taken seriously and addressed early, HIV in Africa would have been different.” (If you want a pdf Daniel’s article, email him at:

In a prominent 1986 paper in the prestigious journal Science, the first head of WHO’s Global Program on AIDS, 1986-91, and the subsequent first director of UNAIDS, 1996-2008, wrote [p 962 in reference 4]: “…one cannot expect public health officials to upgrade blood transfusion services to prevent HIV infection when the proposed intervention is likely to cost, per person, approximately 30 times the annual per capita public health budget. Similarly, one cannot hope to prevent reuse of disposable injection equipment when many hospital budgets are insufficient for the purchase of antibiotics.”

As if this wasn’t enough, when WHO’s experts decided to give a pass to unsafe healthcare in Africa, they didn’t know how serious it would be. There was no evidence at the time – and there still is no evidence – to say with any confidence that blood exposures account for not more than 10% or as much as 50% or 75% or more. The almost exclusive focus on sex was and is based on insufficient evidence.

Although Merson and Inrig recount many events in WHO’s early response to AIDS, they all but ignore what WHO’s experts knew and thought about HIV from unsafe healthcare. The index at the end of the book doesn’t even include these terms: “blood,” “nosocomial,” “iatrogenic,” “injections, medical,” and “scarification.”

Unsafe healthcare was and is the forgotten risk. Africans in large numbers are still getting HIV from this forgotten risk. How many? No one knows.


1. Merson M, Inrig S. The AIDS pandemic: searching for a global response. Switzerland: Springer International, 2018.

2. Fernando D. The AIDS pandemic: searching for a global response. J Assoc Nurses AIDS Care 2018: 29: 635-641. Article available by request from Daniel Fernando at: Abstract available at: 9 January 2019).

3. World Health Organization (WHO). Workshop on AIDS in Central Africa: Bangui, Central African Republic from 22 to 25 October 1985. Geneva; WHO: 1985. Retrieved from

4. Quinn T. C., Mann J. M., Curran J. W., Piot P. (1986). AIDS in Africa: An epidemiologic paradigm. Science, 234(4779), 955-963. Retrieved from

More unexplained HIV infections in KwaZulu-Natal: time to investigate!

Background: Beginning in 2004, the Africa Health Research Institute in KwaZulu-Natal, South Africa, has been testing a random sample of adults for HIV infection in a study area extending about 21 km x 21 km northwest of Mtubatuba town. The study area has one of the worst HIV epidemics in the world: as of 2014, 36% of women and 27% of men aged ≥15 years were infected (about 9,000 out of 30,000 adults)[1,2].

Recently, the Institute “sequenced” HIV (determined the order of small molecules in each HIV) from 1,376 adults in the study area. From these sequences, the Institute found a group (cluster) of 63 very similar sequences. Because HIV sequences change over time, if a cluster of sequences are almost the same, it means HIV from one person not long ago infected everyone in the cluster.

How long did it take for HIV from one person to infect 63 people? The Institute estimated it took one year only, from mid-2013 to mid-2014 for HIV to pass from one person directly and indirectly (through others, in short transmission chains) to 63 people (see the large cluster in the upper right in slide 10 of Coltart’s 2018 presentation).[3]

To go from 1 to 63 infections in 12 months the number of infections doubled almost 6 times – doubling on average every 2 months from 1 to 2 infections, 2 to 4 infections, etc, to 63 infections. Everything we know about sexual transmission of HIV says sex doesn’t do that! With hetero sex, it takes on average 1,000 coital acts for one person to infect another; that takes a lot more than 2 months. Even for male-male sex, it takes ≥30 penis-in-anus events for one transmission; that also takes time.

Such fast transmission is possible when hospitals or clinics reuse unsterilized skin-piercing instruments. Governments investigating unexplained HIV infections have found such tragedies in Russia, Romania, Libya, and other countries.

The cluster of 63 sequences in KwaZulu-Natal looks like a cluster of sequences from an investigated outbreak in Roka, Cambodia: In late 2014, several residents in Roka, a rural community in Cambodia, found they were HIV-positive although they had no sex risks. The Cambodian government investigated, testing all people in the community. The investigation found 242 HIV-positive residents and traced most infections to injections and other skin-piercing procedures from a local private healthcare provider.

Foreign organizations helping with the investigation sequenced several hundred HIV from the community. Almost all sequences were very similar, showing fast transmission from 1 to 198 infections in a few short years. These sequences can be presented as branches in a “tree” (Figure 1, below[4]). The upper right section of the tree shows the cluster of very similar sequences from Roka. (Most sequences in the lower part of the tree are “controls,” which means the HIV came from other times and places.) The tree shows each HIV infection as the right end-point of a horizontal line. The left ends of these lines show estimated connections to earlier estimated infections. Because the cluster includes very recent infections only, all lines in the upper right are very short. The timeline at the bottom of the figure shows time going from left to right, showing the estimated dates of transmission from earlier to later infections.

Figure 1: Cluster of 198 infections in Roka, Cambodia, linked by transmissions during 2011-14[4]

env_timetree_baltic (1)

If 63 sequences from KwaZulu-Natal came from unsafe healthcare, how many people got infected in the outbreak? The cluster of 63 HIV sequences (see slide 10) is from a 15% sample of HIV-positive adults in the study area (1,347 out of an estimated 9,000 infected adults). If someone could sequence HIV from all 9,000, one could expect to find 420 (= 63/0.15) sequences in the cluster, all from people with new and closely linked infections. Moreover, many of the 63 infections came from Mtubaba town on the southwest edge of the study area. If a hospital or clinic in Mtubatuba town was infecting patients, it’s likely the outbreak also extends south and east of the town. Hence, the number of people infected from whatever caused the cluster might well exceed 1,000. And transmission looked like it was continuing when the Institute collected the last HIV samples it sequenced (see slide 10).

What’s the response to this evidence? Investigating the cluster – to find all who have been infected in the outbreak and to find and stop the sources – is a job for public health. As long as the sources of unexpected infections are not found and stopped, public health should also be warning people about blood-borne risks.

If the South African government were to investigate, what could it do? A first task would be to interview people in the cluster to find where they got health care, dental care, tattooing, or other skin-piercing procedures in 2013-14. Once one or more facilities are identified as the possible sources of at least some infections, public health staff could visit the facilities to look for – and fix – dangerous mistakes. At the same time, government could make a public request for people who got skin-piercing procedures at suspected facilities to come for tests. If someone is infected, start treatment. At the same time, investigators could sequence their HIV to see if it’s similar to HIV in the cluster.


1. Vandormael A, Barnighausen T, Herbeck J, et al. Longitudinal trends in the prevalence of detectable HIV viremia: population-based evidence from rural KwaZulu-Natal, South Africa. Clin Infect Dis 2018; 66: 1254-1260. Abstract available at: (accessed 16 November 2018).

2. Larmarange J, Mossong J, Barnighausen T, et al. Participation dynamics in population-based longitudinal HIV surveillance in rural South Africa. PLoS ONE 2015; 10: e012345. Available at: (accessed 16 November 2018).

3. Slide 10 in: Coltart C, Shahmanesh M, Hue S, et al. Ongoing HIV micro-epidemics in rural South Africa: the need for flexible interventions. Conference on Retroviruses and Opportunistic Infections, 4-7 March 2018. Available at: (accessed 4 April 2018).

4. Roka/HIV/bayesian_timetree. Evolutionary and epidemiological analysis of the Roka HIV outbreak. Bedford Lab. Available at: (accessed 15 November 2018). This figure has been copied by permission from Bedford Lab.