Bloodborne HIV: Don't Get Stuck!

Outside Africa, only 3 in 1,000 adults are HIV-positive, and most of these infections concentrate in men who have sex with men (for whom receptive anal sex is the big risk) and injection drug users. Among adults who are neither men who have sex with men or injection drug users, only 1 in 1,000 are HIV-positive.

Africa’s HIV epidemics are different. Not only are more people infected, but HIV also invades and infects the general population – creating what are called “generalized epidemics.” Across Africa, 50 in 1,000 adults (5%) are HIV positive, and few of them are men who have sex with men or injection drug users. In other words, adults in Africa who are neither men who have sex with men nor injection drug users are 50 times more likely to be HIV-positive than are similar adults elsewhere in the world. Moreover, rates of HIV prevalence in some countries in Africa are much higher – in 15 countries from 50 to 260 out of 1,000 adults (5% to 26%) are infected.

Something has to be a lot different in Africa vs. other world regions to explain how so many Africans could be living with HIV. Is it sex, or is it something else? If you know what is different about Africa, you can have a good idea about what are your major risks for HIV, and about how to protect yourself.

Sexual behaviour does not explain Africa’s epidemics

Almost as soon as doctors found Africans with AIDS in the early 1980s, Western AIDS experts started blaming Africa’s epidemics on Africans having huge numbers of sexual partners. At the time, no one had good survey-based information on sexual behaviour in Africa, so the experts took their “evidence” from racial stereotypes. Subsequently, surveys repeatedly found no more heterosexual risk behaviour in Africa than in the US or Europe.ⁱ Nevertheless, many Western experts continue to blame Africa’s HIV epidemics on imagined differences in sexual behaviour.

Moreover, differences in sexual behaviour do not explain differences in HIV epidemics across Africa. For example, women in Moshi, Tanzanian, report more sex partners than women in Harare, Zimbabwe, but have less HIV.ⁱⁱ In short, imaginary or even real differences in sexual behaviour cannot explain Africa’s HIV epidemics.

Among Western AIDS experts, another common explanation for Africa’s epidemics is lack of male circumcision. But male circumcision is less common in Europe than in Africa, yet only 0.5% of European men are HIV-positive, primarily men who have sex with men and injection drug users.

Sterilization of medical instruments is unreliable in Africa

Something that is different between the US and Europe vs. Africa is that use of sterile instruments in health care is reliable in the US and Europe, but not in Africa.

In rich countries as well as in many not-so-rich countries outside Africa, governments make sure that health care providers use sterile instruments. If there is evidence that someone reuses unsterilized instruments, governments arrange for an investigation, and make sure the errors are corrected. For example, in January 2011, a clinic in Australia found that a nurse had reused a needle for blood tests on 55 people. The clinic reported what had happened to the government, corrected the error, and arranged blood tests for all 55 patients – to see if reused instruments had infected any of them with HIV, hepatitis B, or hepatitis C.ⁱⁱⁱ

In contrast, reuse of unsterilized instruments is common in many African hospitals and clinics. Recent surveys of public and private hospitals and clinics in 7 African countries found that 17% to 83% of facilities did not have equipment to sterilize reused instruments (see Table: Hospitals and clinics). Moreover, just having equipment does not assure that it is used, and that instruments have been sterilized. The same surveys reported that many facilities with equipment did not have staff trained to operate it. Power cuts may be a problem. And carelessness and human errors are also possible.

Table: Hospitals and clinics lack equipment to sterilize instruments

* Equipment for autoclaving, boiling, dry heat, or high level chemical disinfection.

Sources: Percentages of facilities with equipment to sterilize instruments are from the latest Service Provision Assessments for each country, available at: http://www.measuredhs.com/pubs/search/search_results.cfm?Type=21&srchTp=type&newSrch=1 (accessed 8 July 2011). Percentages of adults who are HIV-positive are from UNAIDS.

What was the response? No government investigated to see if anyone got HIV or other infection from reused instruments. No government or donor responded with an urgent, high-priority program to ensure no more reuse of unsterilized instruments. The situation continues.

In all countries where medical instruments are reliably sterile – where governments investigate reports that instruments have been reused without sterilization – HIV concentrates in men who have sex with men and injection drug users. No country with reliable sterilization of medical instruments has a generalized epidemic.

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i Wellings K, Collumbien M, Slaymaker E, et al. Sexual behavior in context: A global perspective. Lancet 2006; 368: 1706-28.