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What’s different about Africa – sex or unsterile instruments?

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

Country, year of survey % of hospitals and clinics without equipment* to sterilize instruments % of adults with HIV infections, 2009
Ghana, 2002



Kenya, 2009



Namibia, 2009



Rwanda, 2007



Tanzania, 2006



Uganda, 2007



Zambia, 2005



* 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: (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 has 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.

African governments do not investigate unexplained HIV infections

Another thing that is different in Africa vs. non-African countries with concentrated HIV epidemics is that no African government has investigated any unexplained HIV infection, whereas other governments routinely investigate them.

Unexplained infections are common in Africa. For example, recent national surveys in Swazilandiv and Mozambiquev found 20%-30% of HIV-positive children to have HIV-negative mothers (among children with tested mothers). Unexplained infections are also common in adults with no sexual risks, such as in virgins. For example, a recent national survey in Congo (Brazzaville) found that 4.2% of women who said they were virgins were HIV positive vs. only 4.1% of all

These infections are evidence that some hospital or clinic may be reusing instruments without sterilization, spreading HIV from one patient to another. What is required to find the source of these infections, and to prevent more infections, is to identify the hospital or clinic that treated people with unexplained infections, and then to trace and test other patients to see if they are also infected. No African government has investigated any of these infections. The lack of response is like smelling smoke, but then going back to sleep and letting the house burn down.

In contrast, ministries of health in Russia, Romania, Libya, Kazakhstan, and other countries have investigated unexplained HIV infections (see Table: Investigated HIV outbreaks). For example, in 1989, doctors in a Romanian hospital found several children with HIV but with HIV-negative mothers. In response, doctors and the government tested thousands of children in 1989-91, and found more than 1,000 who had been infected by medical procedures. Investigations alerted the public and providers to risks. Currently, Romania has a concentrated epidemic with less than 1 in 1,000 people infected – one of the lowest rates in the world.

Table: Investigated HIV outbreaks from blood-to-blood transmission*

Country, year of outbreak

Who was infected

Number of cases

Mexico, circa 1986vii

Blood and plasma sellers


Russia, Elista, 1988-89viiiixxxi

Inpatient children


Romania, 1987-1992xiixiiixiv



India, Mumbai, 1988xv

Blood and plasma sellers


China, 1990-95xvixviixviii

Blood and plasma sellers


Libya, 1997-99xixxx

Inpatient and outpatient children


Kazakhstan, 2006xxixxii Inpatient children


Kyrgyzstan, 2007xxiiixxivxxv Inpatient children


Uzbekistan, 2008xxvi Inpatient children


* Outbreaks with 100 or more infections.

All of the countries that investigated unexplained infections to find hundreds to thousands of infections had problems with reuse of instruments without sterilization. The investigations that uncovered and reported these infections alerted both providers and the public to be careful. And that was enough to stop unsafe practices. No country that has investigated unexplained HIV infections has a generalized epidemic.


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

ii Mapingure MP, Msuya S, Kurewa NE, et al. Sexual behaviour does not reflect HIV-1 prevalence differences: a comparison study of Zimbabwe and Tanzania. J Inter AIDS Soc 2010; 13: 45. Available at: (accessed 9 July 2010).

iiiMerhab B. Clinic Bungle Leaves 55 at HIV Risk. Australian Associated Press, 9 February 2011. Available at: (accessed 9 February 2010).

ivOkinyi M, Brewer DD, Potterat JJ (2009) Horizontally acquired HIV infection in Kenyan and Swazi children. Int J STD AIDS 20: 852-857. Summary data available at: (accessed 8 July 2011).

v See pp. 177-181 in: Instituto Nacional de Saúde (INS), Instituto Nacional de Estatística (INE), e ICF Macro. 2010. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. Calverton, Maryland, EUA: INS, INE e ICF Macro. Available at: (accessed 8 July 2011).

viSee Table 7.5 in: Centre National de la Statistique et des Études Économiques (CNSEE). Enquête de Séroprévalence et sur les Indicateurs du Sida du Congo (ESISC-I) 2009. Brazzaville: CNSEE, 2009. Available at: (accessed 8 July 2011).

vii Avila C, Stetler HC, Sepúlveda J, et al. The epidemiology of HIV transmission among paid plasma donors, Mexico City, Mexico. AIDS 1989; 3: 631-3.

viii Bobkov A, Garaev MM, Rzhaninova A, et al. Molecular epidemiology of HIV-1 in the former Soviet Union: analysis of env V3 sequences and their correlation with epidemiologic data. AIDS 1994; 8: 619-624.

ix Pokrovskii VV, Eramova II, Deulina MO, et al. An intrahospital outbreak of HIV infection in Elista [in Russian]. Zh Microbiol Epidemiol Immunobiol 1990, 4: 17-23.

x Pokrovsky VV. Localization of nosocomial outbreak of HIV infection in southern Russia in 1988-89. 8th Int Conf AIDS, Amsterdam 19-24 July 1992; abstract no. PoC 4138.

xi Sauhat SR, Kotova EA, Prokopenkova SA, et al. Risk factors for HIV transmission in hospital outbreak. 8th Int Conf AIDS, Amsterdam 19-24 July 1992, abstract no. PoC 4288.

xii Patrascu IV, Dumitrescu O. The epidemic of human immunodeficiency virus infection in Romanian children. AIDS Res Hum Retroviruses 1993; 9: 99-104.

xiii Apetrei C, Loussert-Ajaka I, Collin G, et al. HIV type 1 subtype F sequences in Romanian children and adults. AIDS Res Hum Retroviruses 1997; 13: 363-5.

xiv Drucker E, Apetrei C, Heimer R, et al. The role of unsterile injections in the HIV pandemic. In Sande MA, Volberding PY, Lange J, et al. Global HIV/AIDS Medicine. Philadelphia: Saunders, 2007. pp. 755-67.

xv Bhimani GV, Gilada IS. HIV prevalence in people with no fixed abode – A study of blood donorship patterns and risk determinants. 8th Int Conf AIDS, Amsterdam 19-24 July 1992; abstract MoC00937.

xvi Wu Z, Liu Z, Detels R. HIV-1 infection in commercial plasma donors in China [letter]. Lancet 1995; 346: 61-2.

xvii Wu Z, Rou K, Detels R. Prevalence of HIV infection among former commercial plasma donors in rural eastern China. Health Policy Plan 2001; 16: 41-6.

xviii Ministry of Health, China, UNAIDS, WHO. 2005 Update on the HIV/AIDS epidemic and response in China. Geneva: WHO, 2006.

xix Visco-Comandini U, Cappiello G, Liuzzi G, et al. Monophyletic HIV type 1 CRF02-AG in a nosocomial outbreak in Benghazi, Libya. AIDS Res Hum Retroviruses 2002; 18: 727-32.

xx de Oliviera T, Pybus OG, Rambaut A, et al. HIV-1 and HCV sequences from Libyan outbreak. Nature 2006; 444: 836-7.

xxi Kazakhstan: more HIV-infected children found in southern Kazakhstan. RadioFreeEurope/RadioLiberty, 3 October 2007. Available at: (accessed 10 October 2007).

xxii In the courts: Health workers sentenced to prison in Kazakhstan for criminal negligence after HIV outbreak among women, children., 2 January 2008. Available at: (accessed 27 March 2009).

xxiii Shersen D. Kyrgyzstan: Officials grapple with HIV outbreak. EurasiaNet, 30 October 2007. Available at: (accessed 1 November 2007).

xxiv Thome C, Ferencic N, Malyuta R, Mimica J, Niemiec T. Central Asia: hotspot in the worldwide HIV epidemic. Lancet Infect Dis 2010; 10: 479-488.

xxv AP/Houston Chronicle examines HIV outbreak among 72 children, 16 mothers through tainted blood and used needles., 11 April 2008. Available at: (accessed 27 March 2009).

xxvi Thome C, Ferencic N, Malyuta R, Mimica J, Niemiec T. Central Asia: hotspot in the worldwide HIV epidemic. Lancet Infect Dis 2010; 10: 479-488.

2 responses to “What’s different about Africa – sex or unsterile instruments?

  1. Pingback: Could Chinese Transfusion Service Have Infected HIV Positive Man? « Don't Get Stuck With HIV

  2. Pingback: Respecting women’s human rights by telling them about all their HIV risks « Don't Get Stuck With HIV

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