Bloodborne HIV: Don't Get Stuck!

Protect yourself from bloodborne HIV during healthcare and cosmetic services

Tag Archives: hospital transmitted infections

WHO’s and UNAIDS’ response: If there’s a problem, we warned Africans

On 15 October, three managers of dontgetstuck along with five other experts sent an Open Letter to the heads of WHO, UNAIDS, and World Bank, challenging them to warn and protect Africans from HIV through health care. There is no indication that Chan, Sidibe or Kim read the letter. The only response we have received is from De Lay of UNAIDS and Nakatani of WHO (see below).

The response, which falls short of what WHO and UNAIDS could do under the circumstances, leads to several questions:

Question 1: If the evidence we presented (16%-31% of HIV-positive children with HIV-negative mothers) had come from Europe, would WHO and UNAIDS let it go by without recommending urgent actions to correct whatever happened to infect children?

Even asking this question brings the realization that governments and populations in Europe would not wait to see what WHO or UNAIDS said about the situation – they would insist on investigations to find how children had been infected and thereby to ensure that their health care is safe. We can see such investigations in Russia under Gorbachev, Romania under Ceausescu, Libya under Kaddafi, Kazakhstan, Kyrgyzstan, and Uzbekistan – all of which countries acted without waiting for WHO advice or assistance.

Question 2: Since WHO and UNAIDS have not recommended a specific response to evidence of large numbers of HIV-positive African children with HIV-negative mothers, who if anyone is going to respond to protect African children?

De Lay and Nakatani say that WHO and UNAIDS have warned African governments about unsafe health care, in effect putting the onus on Africans to respond to the evidence in the Open Letter. Whether the onus belongs there or not, it seems clear that WHO and UNAIDS are not ready to do more to protect African children from unsafe health care. Will African governments step up, or will they take the low road, like WHO and UNAIDS, letting things go on and on?

[See also Simon Collery’s comments on WHO’s and UNAIDS’ reply, with information about health care conditions in Africa.]

WHO’s and UNAIDS’ letter responding to Open Letter

23 October 2012

Dear Dr Gisselquist and colleagues,

Thank you for the open letter sent to Mr Sidibe, Dr Chan and Dr Kim on 15 October, 2012. We recognize that unsafe injections, skin piercing, blood transfusions and surgical procedures can contribute to HIV transmission, and advise countries that an effective HIV response should take into account all available data on modes of transmission in the design and implementation of their response.

As part of our commitment to reducing HIV incidence and new HIV infections, both the World Health Organization (WHO) and UNAIDS have produced guidance with unsafe skin-piercing procedures. UNAIDS Prevention Policy Paper, and the WHO Global Health Sector Strategy on HIV/AIDS, 2011-2015 make explicit reference to the importance of preventing unsafe injections, surgical practices and blood transfusions. WHO and UNAIDS advise countries to scale up proven and cost-effective strategies, policies and programmes that are tailored to their actual HIV epidemic and its social, economic and health system context (Know Your Epidemic/Know Your Response).

Recently, WHO’s Director-General, Dr Margaret Chan called for action on injection safety. Since this call, a cross-departmental working group has been created to develop a policy document and implementation plan on the safety of all therapeutic injections.

Thank you for raising these issues in the letter and for your efforts in the fight against HIV.

Best regards,

Paul De Lay, Deputy Executive Director, Programme, UNAIDS
Dr Hiroki Nakatani, Assistant-Director General, HIV/AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases, WHO

An open letter to Michel Sidibé, Executive Director of UNAIDS, Margaret Chan, Director-General of WHO, and Jim Kim, President of the World Bank

Dear Colleagues,

We commend your organizations’ efforts to treat people infected with HIV and to prevent mother-to-child HIV transmission. Such efforts should be continued and expanded. Unfortunately, that will not be enough to stop almost two million Africans from contracting HIV each year.

This letter is spurred by results released in September 2012 from a national survey in Uganda in 2011. We call your attention to one of the findings: 16% of HIV infected children age 0-5 years had HIV-negative mothers, among children with tested mothers. This is the 4th national survey in Africa to match the HIV status of children and mothers. In the three previous surveys, Uganda in 2004-05, Swaziland in 2006-07, and Mozambique in 2009, 16%-31% of HIV-positive children had HIV-negative mothers (see survey reports at: see also analyses of raw data for Mozambique and Swaziland at: Int J STD AIDS 2009, 20:852-7; and

To help stop HIV transmission through skin-piercing procedures in health care and cosmetic services, we urge your organizations to tell the African public what UNAIDS and WHO already tell UN, including World Bank, employees: “unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections” (p. 9 in:, and “avoid having injections unless they are absolutely necessary… Avoid tattooing and ear piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized” (p. 23 in:

Warning the public about blood-borne risks for HIV not only allows people to avoid risks, but also empowers and motivates the public to hold their health caretakers (both formal and informal), providers of cosmetic procedures, and ministries of health to a high standard of safety.

Available evidence suggests that warning people about blood-borne risks could have a significant impact on HIV epidemics. During 2003-07, national surveys in 16 African countries asked people how to prevent HIV. In countries where more people said that avoiding contaminated instruments such as razor blades was a way to prevent HIV infection, people were less likely to be infected (see Figure).

Figure: Percent of adults with HIV vs. percent aware of blood-borne risks

Percentage of adults with HIV vs. percentage aware of blood-to-blood risks

Percentage of adults with HIV vs. percentage aware of blood-to-blood risks

Source: For each country, the percent of adults who say “avoid sharing razors/blades” is the average of percents for men and women from 16 surveys, excluding adults who were not aware of HIV or had been previously tested for HIV, as reported in: J Infect Dev Ctries 2011; 5: 182-198, Percents of adults with HIV (except for DRC and Ethiopia) are for 2009 from: UNAIDS, Report on the Global Epidemic 2010; for DRC and Ethiopia these are for 2007 and 2005, respectively, from national surveys available at:

The World Medical Association’s Declaration of Lisbon on the Rights of the Patient ( avers that each patient has “the right to the information necessary to make his/her decisions.” We ask you to ensure that your organizations adhere to this principle by emphasizing blood-borne risks in HIV prevention education and by making safety a priority in all programming with health care and cosmetic service providers and institutions.


Dr. David Gisselquist dontgetstuck   collective,
John J.   Potterat Independent   STD/HIV consultant,
Dr. Deena   Class Global health   & development consultant
Simon   Collery Dontgetstuck   collective,
Dr.   Joseph Sonnabend
Dr.   Janet S. St. Lawrence, Professor   Emerita, Mississippi State University
Dr.   Mariette Correa Associate   Professor, Tata Institute of Social Sciences, Guwahati, India
Dr.   Wallace Dinsmore Consulting   Physician, Royal Victoria Hospital, Belfast
Dr.   François Vachon Emeritus Professor, Denis Diderot University, Paris,   France

Break the silence: Stop HIV transmission through health care and cosmetic procedures (part 3 of 3)

[this is the 3rd of 3 parts; click here to get the complete paper]

6.         Wherever governments investigate unexpected HIV infections, HIV concentrates in MSMs and IDUs

An unexpected infection – for example, in a child with an HIV-negative mother or a woman with one lifetime HIV-negative sex partner – is a warning that people may be getting infections from an unknown source. Many governments outside Africa have reacted to unexpected infections by investigations – tracing and testing patients who attended specific hospitals or clinics suspected to be the source of the unexpected HIV infection (Table). Such investigations are able to stop further damage by finding others who are infected and thereby identifying the procedures and errors that led to infections. No country in which the government investigated unexpected HIV infections has a generalized epidemic.

Table: Investigated HIV outbreaks from unsafe health care procedures (outbreaks with 100 or more infections)

Country,   year of outbreak Who   was infected Number   of cases
Mexico, circa   1986[1] Blood   and plasma sellers 281
Russia, Elista, 1988-89[2] Inpatient   children >260
Romania, 1987-1992[3] Children ~10,000
India, Mumbai,   1988[4] Blood   and plasma sellers ~172
China, 1990-95[5] Blood   and plasma sellers ~100,000
Libya, 1997-99[6] Inpatient   and outpatient children >400
Kazakhstan, 2006[7] Inpatient   children >140
Kyrgyzstan,   2007[8] Inpatient   children >140
Uzbekistan,   2008[9] Inpatient   children >140

For example, in 1989, doctors in a Romanian hospital found several children with HIV but with HIV-negative mothers. In response, doctors and later the government tested thousands of children in 1989-91, found more than 1,000 with HIV, and determined that most infections came from injections. Investigations alerted the public and providers to demand and ensure safe care. Currently, less than 0.1% (1 in 1,000) of Romanians are infected – one of the lowest levels in the world.

In contrast, even though unexpected infections are common in sub-Saharan Africa, no African government has investigated any unexpected HIV infection by tracing and testing other patients who attended a suspected clinic or hospital. The failure to investigate is like smelling smoke, but then going back to sleep and letting the house burn down. Here are some unexpected infections that African governments could have and should have investigated, but didn’t:

Unexplained infections are also common in adults with no sexual risks, including virgin men and women. For example:

7.         Wherever governments react to stop unsafe health care, HIV concentrates in MSM and IDUs

In the US and Europe, governments arrange several mechanisms to find and stop reuse of unsterilized skin-piercing instruments in health care. These mechanisms include regulations describing acceptable practices, licenses, inspections, and courts that allow patients to sue for damages. When someone reports unsafe procedures in a health facility, inspectors visit the facility. If the error is considered dangerous to pass infections among patients, governments may trace and test patients.

In the US and Europe, it’s not only governments that are vigilant about risks to get HIV from blood, so is the general public. For example, if a participant in a sporting contest gets a bleeding cut, referees send him or her to the sidelines. The player is not allowed to return to the game until his or her cut has been covered.

In contrast to what happens in the US and Europe, unsafe procedures are common and tolerated in Africa. As already reported at the beginning of this note, many health care facilities lack equipment to sterilize instruments, and many people accept cosmetic services in public places with unsterilized instruments that could pierce their skin.

Break the silence

Health care professionals from Geneva to African ministries of health to hospitals and clinics in towns and cities across Africa have largely ignored HIV transmission through health care. As far as I can see, their silence comes at least in part from not wanting or not knowing how to tell the public there is a problem. Because health care professionals have not wanted to talk about the problem, it’s up to the public at risk to break the silence. Here are some suggestions about what people can do to break the silence and thereby to protect themselves and others.

Avoid contaminated instruments: People who are aware of blood-borne risks can avoid contaminated skin-piercing instruments. A general strategy to do so boils down to four options: avoid the procedure, use disposable instruments, patients/clients sterilize instruments, or talk with providers to ensure they sterilize instruments. Further suggestions about this strategy are available at:, with pages on injections, tattooing, etc.

Talk about unexpected infections: Individual efforts to avoid unsterilized instruments do not always work. People may not feel comfortable asking a doctor or nurse if instruments have been sterilized. Moreover, in a lot of situations – such as in an emergency – people have little or no chance to control the instruments used on them. In other words, to be really safe from blood-borne HIV people need to ensure that hospitals and clinics in their communities are not making careless errors.

Investigations are the key to finding and stopping errors. People who are aware of risk can help to lay the groundwork for investigations by talking with others in their communities about risks to get HIV from skin-piercing procedures. Then, whenever an unexpected infection gets recognized in the community, more people will be aware of their own risk, and could work together to push for investigations through political leaders, the media, and courts.

The objective of an investigation should not be to punish anyone or to collect damages for victims but rather to find others who have been infected and thereby to find and stop errors. Many African governments already offer free treatment for HIV, so victims can get care. During investigations, health staff should be assured they will not be blamed or punished for errors.

HIV prevention programs aimed exclusively at sexual transmission have failed to stop HIV in Africa – they do not protect people from all risks. People at risk can do something different to get different results: beware unsterile skin-piercing instruments, and break the silence to urge their communities and governments to address blood-borne and not only sexual risks.

[1] Avila C, et al; AIDS 1989; 3: 631-3.

[2] Bobkov A, et al; AIDS 1994; 8: 619-624. Pokrovskii VV, et al. Zh Microbiol Epidemiol Immunobiol 1990, 4: 17-23. Pokrovsky VV; 8th Int Conf AIDS, Amsterdam 19-24 July 1992; abstract PoC 4138. Sauhat SR, et al; 8th Int Conf AIDS, Amsterdam 19-24 July 1992, abstract PoC 4288.

[3] Patrascu IV, Dumitrescu O; AIDS Res Hum Retroviruses 1993; 9: 99-104. Apetrei C, et al. AIDS Res Hum Retroviruses 1997; 13: 363-5. Drucker E, et al; In Sande MA, et al; Global HIV/AIDS Medicine; Philadelphia: Saunders, 2007.

[4] Bhimani GV, Gilada IS; 8th Int Conf AIDS, Amsterdam 19-24 July 1992; abstract MoC00937.

[5] Wu Z, et al; Health Policy Plan 2001; 16: 41-6. Wu Z, et al; Lancet 1995; 346: 61-2. UNAIDS, 2005 Update on the HIV/AIDS epidemic and response in China; WHO, 2006.

[6] Visco-Comandini U, et al. AIDS Res Hum Retroviruses 2002; 18: 727-32. de Oliviera T, et al; Nature 2006; 444: 836-7.

[7] Kazakhstan: more HIV-infected children…; RadioFreeEurope/RadioLiberty, 3 October 2007. Available at: (accessed 10 October 2007). In the courts: Health workers sentenced…, 2 January 2008. Available at: (accessed 27 March 2009).

[8] Shersen D; Kyrgyzstan: Officials grapple…; EurasiaNet, 30 October 2007. Available at: (accessed 1 November 2007). Thome C, et al; Lancet Infect Dis 2010; 10: 479-488. AP/Houston Chronicle examines HIV outbreak…;, 11 April 2008. Available at: (accessed 27 March 2009).

[9] Thome C, et al; Lancet Infect Dis 2010; 10: 479-488.

[10] Mann JM, Francis H, Davachi F, et al. ‘Risk factors for human immunodeficiency virus seropositivity among children 1-24 months old in Kinshasa, Zaire’, Lancet, 1986, ii: 654-7.

[11] Lepage P, Van de Perre P, Carael M, et al. ‘Are medical injections a risk factor for HIV in children?’, Lancet, 1986, ii: 1103-4.

[12] Lepage P, Van de Perre P. Nosocomial transmission of HIV in Africa: What tribute is paid to contaminated blood transfusions and medical injections? Infect Control Hosp Epidemiol 1988, 9: 200-3.

[13] 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’, 9th Int Conf AIDS, Berlin 6-11 June 1993. Abstract no. WS-C13-2. Available at: (accessed 9 September 2007).

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

[15] ORC Macro. Uganda HIV/AIDS Sero-Behavioural Survey 2004-05. ORC Macro: Calverton, Maryland, 2006. Available at: at (accessed 21 September 2012).

[16] Ministry of Health, Kampala. Uganda AIDS Indicator Survey 2011. Calverton: ICF International, 2012. Available at: (accessed 22 September 2012).

[17] Okinyi 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).

[18] 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 17 October 2012).

[19] See 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).

[20] Ministry of Health, Kampala. Uganda AIDS Indicator Survey 2011. Calverton: ICF International, 2012. Available at: (accessed 22 September 2012).

Break the silence: Stop HIV transmission through health care and cosmetic procedures (part 2 of 3)

[this is the 2nd of 3 parts; click here to get the complete paper]

3.         In African countries where more people are aware of blood-borne risks, fewer people have HIV

During 2003-07, national surveys in 16 African countries asked people how to prevent HIV. In these surveys, the percent of adults who mentioned “avoid sharing razors/blades” as a way to prevent HIV ranged from 10% in Swaziland to almost 50% in Niger and Ethiopia. In five countries where less than 15% of adults recognized contaminated razors or blades as risks for HIV (Kenya, Lesotho, Swaziland, Tanzania, and Zimbabwe) the percentages of adults with HIV ranged from 5.6% to 26%. On the other hand, in six countries where at least 30% mentioned razors or blades (Democratic Republic of Congo [DRC], Ethiopia, Ghana, Niger, Rwanda, and Senegal) only 0.8% to 2.9% of adults were HIV-positive (Figure).

Figure: Percentages of adults with HIV vs. percentages aware of blood-borne risks

Percentage of adults with HIV vs. percentage aware of blood-to-blood risks

Percentage of adults with HIV vs. percentage aware of blood-to-blood risks

Note: the equation for the correlation is y = 20.2 – 0.53x. Source: For each country, the percent who say “avoiding sharing razors/blades” is the average of percents for men and women, excluding those not aware of HIV or who had been previously tested for HIV, from: Brewer DD. Knowledge of blood-borne transmission risk is inversely associated with HIV infection in sub-Saharan Africa. J Infect Dev Ctries 2011; 5: 182-198. Available at: (accessed 7 July 2011). Percentages of adults with HIV (except for DRC and Ethiopia) are for 2009 from: UNAIDS Report on the Global Epidemic 2010, available at: (accessed 4 July 2011); for DRC and Ethiopia these percentages are for 2007 and 2005, respectively, from national surveys available at:

4.         The best available evidence from Africa says that sex accounts for less than half of HIV infections in adults

During 1987-2011, 44 studies in Africa tested interventions to protect adults from HIV and reported their results. These 44 studies followed a total of more than 120,000 adults and observed a total of 4,029 new infections.[1] In most studies, the intervention failed – it had little or no impact on how fast people got HIV. But even though most interventions failed, these studies nevertheless provide some insights into how and why so many Africans are getting HIV.

The surest way to say how many of these 4,029 infections came from sex is to trace and test sexual partners; then, if any partners have HIV, sequence it to see if it matches HIV from the new infection. Only 4 of 44 studies did so, tracing a total of only 186 (4.6%) of 4,029 infections to sexual partners with similar HIV. Thus, according to these best criteria, we don’t know the sources of the other 95.4% of infections.

The second best way to say how many of these infections came from sex is to see how fast people with sexual risks got HIV compared to people with no sexual risks. Five of the 44 studies report rates of new HIV infections in men and/or women who did and did not report any possible sexual exposure to HIV. Here’s what they found:

  • In a study among men in South Africa in 2002-05,[2] men who reported no sex partner or 100% condom use (ie, no possible sexual exposure to HIV) got HIV at the rate of 1.11% per year compared to 1.86% for men who reported possible sexual exposure (at least one sex partner and less than 100% condom use). Having reported sexual exposures increased risk by a factor of 1.7 (= 1.86/1.11) times.
  • In a similar study among men in Uganda in 2003-06,[3] men who reported no partner or 100% condom use got HIV at the rate of 0.72% per year vs. 1.17% per year for men who reported one or more sex partners and less than 100% condom use. Having reported sexual exposures increased risk by a factor of 1.6 (= 1.17/0.72) times.
  • In a trial among women in South Africa reported in 2011, 1 (20%) of 5 women who reported no sex partners during the trial got HIV compared to 97 (11%) of 884 women who reported one or more sex partners. Having reported sexual exposures reduced risk by a factor of 0.55 (= 11/20) times.[4]
  • In a trial among men and women in Zimbabwe in 1998-2003, reporting one or more vs. no sex partners over a period of 3 years increased risk to get HIV by a factor of only 1.3 among women, and by a factor of 2.5 among men.
  • In a trial in Uganda in 1994-98,[5][6] men and women who reported one or more sex partners over 2 years got HIV 2.7 times faster than men and women who reported no sex partners.

Combining information from all five studies, the median (middle) impact of reported sexual risk on an adult’s rate to get HIV was 1.65. This result – that possible sexual exposure to HIV fell far short of doubling his or her risk to get HIV – suggests that sex accounts for far less than half of new HIV infections among adults.

Faced with such evidence, study teams supposed that participants lied about their sexual behavior and continued to aver that most HIV came from sex. It’s also notable that study teams for most trials – 39 out of 44 – did not say how many people with new HIV infections reported no possible sexual exposures to HIV, even though most studies collected information on numbers of partners. By disbelieving and withholding evidence, study teams are in effect saying that evidence is not necessary – that they know without and even despite evidence that almost all HIV infections in Africa come from sex.

5.         Many studies in Africa find HIV infections best explained by blood contacts

In 2001, UNAIDS hired Nicole Seguy to review evidence linking injections to HIV. Compiling data from all available studies that had followed HIV-negative adults to find new infections, and that had asked about and reported injections, she concluded: “contaminated injections may cause between 12% and 33% of new HIV infections” in Africa.[7]

Seven of the 44 trials mentioned above report information on blood exposures for adults with new infections, including:

Aside from these trials, a lot of other evidence links HIV to injections and other skin-piercing risks, for example:

Much more evidence is available at:; in a history of AIDS in Africa at:; in selected papers by Gisselquist at:; and in many of Devon Brewer’s recent papers at:

[1] Gisselquist D. Randomized controlled trials for HIV/AIDS prevention among men and women in Africa: untraced infections, unasked questions, and unreported data. SSRN 2011. Available at: (accessed 18 September 2012).

[2] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005; 2(11): e298. Available at:  (accessed 15 September 2012).

[3] Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657-666.

[4] Karim QA, Karim SSA, Frolich JA, et al. Effectiveness and safety of tenofovir gel, an antiviral microbicide, for the prevention of HIV infection in women. Science 2010; 329: 1168-1174. Available at: (accessed 15 September 2012).

[5] Ahmed S, Lutalo T, Wawer M, et al. HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS 2001; 15: 2171-2179.

[6] Wawer MJ, Sewankambo NK, Serwadda D, et al. Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomized community trial. Lancet 1999; 353: 525-535.

[7] Randerson J. WHO accused of huge HIV blunder. New Scientist, 6 December 2003, 180 (2424): 8-9.

[8] Watson-Jones D, Baisley K, Weiss HA, et al. Risk factors for HIV incidence in women participating in an HSV suppressive treatment trial in Tanzania. AIDS 2009; 23: 415-422.

[9] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005; 2(11): e298. Available at:  (accessed 15 September 2012).

[10] Auvert B, Sobngwi-Tambekou J, Taljaard D, Lagarde E, Puren A (2006) Authors’ Reply. PLoS Med 3(1): e67. Available at: (accessed 15 October 2012).

Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005; 2(11): e298.

[11] Whitworth JA, Birao S, Shafer LA, et al. ‘HIV incidence and recent injections among adults in rural southwestern Uganda’, AIDS, 2007, 21: 1056-8.

[12] The 10 countries are: Cameroon, Ethiopia Ghana, Guinea, Kenya, Lesotho, Senegal Malawi, Rwanda, and Zimbabwe.

[13] Brewer DD, Roberts JM, Potterat JJ. Punctures during prenatal care associated with prevalent HIV infection in sub-Saharan African women. International Society for Sexually Transmitted Diseases Research, Seattle 2007.

[14] Brewer DD. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. WebmedCentral Epidemiology 2011;2(9):WMC002206. Available at: (accessed 16 January 2012).

Break the silence: Stop HIV transmission through health care and cosmetic procedures (part 1 of 3)

[this is the first of three parts; click here to get the complete paper]

 Insanity is doing the same thing, over and over again, but expecting different results.[1]

The common explanation for HIV epidemics in sub-Saharan Africa is that sex between men and women accounts for almost all infections in adults. Considering the long-term failure of programs focusing almost exclusively on sex to roll back high levels of HIV infection in Africa, it’s time to step back and take a fresh look at the situation.

Sterilization of reused instruments is unreliable in many health care settings in Africa. In national surveys of hospitals and other health care facilities in seven countries (Ghana, Kenya, Namibia, Rwanda, Tanzania, Uganda, and Zambia) during 2002-10, from 17% of facilities in Rwanda to 83% in Namibia did not have equipment to sterilize instruments (the median among seven countries was 33% without equipment).[2] Reuse of unsterilized skin-piercing instruments is common in cosmetic services as well. For example, in Kampala, Uganda, people get manicures on the street from itinerant providers who reuse instruments from one client to another.

Wherever skin-piercing instruments are reused without sterilization people can get HIV from traces of blood from a previous patient or client. HIV can live for hours in dry blood,[3] such as on a razor, and for weeks if kept wet, such as in a used syringe or needle. Boiling reliably kills HIV, but wiping and even soaking with bleach or spirits does not, except under controlled conditions.

Recognizing these risks, WHO warns UN employees that[4]unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections,” in unspecified world regions, but assures them: “Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.”

WHO further warns UN employees [5]If you are not carrying your own syringes and needles, avoid having injections unless they are absolutely necessary,” and “Avoid tattooing and ear piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized.”

It’s clear from WHO advice to UN employees that skin-piercing procedures are not the minor risks for HIV that HIV prevention messages have misled Africans to believe. Based on available evidence, it’s possible – even likely – that more than half of African adults with HIV got it from blood contact or from a spouse or other sex partner who got it through blood contact.[6] Here’s some of the evidence (summarized here, expanded below):

1.     No one has explained how heterosexual sex[7] could infect such high percentages of adults in Africa but not elsewhere.

2.     Sexual transmission was not enough to create an HIV epidemic in Africa before 1900.

3.     Across Africa, in countries where more people are aware of blood contacts as risks for HIV, the percent of adults infected with HIV is less.

4.     Many studies in Africa that follow HIV negative adults to see who gets HIV find that those who report no sex partners or 100% condom use get HIV almost as fast as adults who report possible sexual exposure to HIV.

5.     Many studies in Africa report HIV infections linked to medical injections, blood tests, circumcision, and other blood exposures.

6.     In countries where governments investigate unexpected HIV infections, HIV concentrates in injection drug users and men who have sex with men.

7.     In countries where governments react to stop unsafe practices in health care, HIV similarly concentrates in injection drug users and men who have sex with men.

Following sections elaborate this evidence. This note concludes with some suggestions about how Africans can “break the silence” to protect themselves and their families and to stop Africa’s HIV epidemics.

1.         Low percentages of adults get HIV from heterosexual sex outside Africa

Outside Africa, only 0.3% of adults (3 in 1,000) are HIV-positive, and HIV infects twice as many men as women.[8] In much of the world, HIV infections concentrate in adults with specific high risk behaviors – men who have receptive anal sex with men (MSM), and people who reuse syringes and needles to inject illegal drugs (IDU). Notably, the biggest risk for HIV among prostitute women in much of the world is IDU, not sex.

In the US and Europe, many men who are MSM and IDUs have sex with women, and many women who are IDUs sell sex to pay for drugs. Although MSM and IDUs thereby infect some heterosexual partners, their partners on average die before passing it on. In other words, heterosexuals in the US and Europe are “dead ends,” not “drivers” of the epidemic.

In contrast, in 14 countries[9] in Africa, 5%-26% of adults aged 15-49 years are infected, more women than men. The common explanation for such high levels of HIV infection among “low risk adults” (ie, not MSM or IDU) in Africa is that somehow heterosexual transmission is faster and more efficient in Africa. But no one has explained how that could be so. Transmission between discordant couples is similar across countries. Sexual behavior in Africa is similar to behavior in the US and Europe. Male circumcision is more common in Africa than in Europe.

2.         No heterosexual HIV epidemic in Africa before 1900

HIV in humans comes from simian immunodeficiency virus (SIV) in chimpanzees and gorillas. Scientists can “sequence” individual HIV and SIV, describing the order of their component parts. Because sequences change over time, viruses whose sequences are more similar are more closely related – ie, they have a more recent common ancestor that lived in a human, chimpanzee, or gorilla some time ago.

A comparison of HIV and SIV sequences reveals four groups of HIV, each of which resulted from a different event in which SIV from a chimpanzee or gorilla got into a human. We know this because the HIV sequences in each of these groups are more similar to some of the SIV from chimpanzees or gorillas than to HIV in the other three groups. Also, from studying the differences among HIV sequences within each group, scientists can estimate that HIV in the two oldest groups began to spread among humans around 1900.[10]

Thus, we can surmise that SIV passed from chimpanzees and gorillas to humans at least four times in the last 100 years or so.[11] The best explanation for how this happened is that hunters and butchers got SIV-contaminated blood into cuts, giving them HIV infections. If this happened four times in the recent past, it likely happened hundreds of times in the past 100,000 years. We know that chimpanzees have been infected with SIV for at least that long, because distantly related SIV can be found in two populations east and west of the Congo River which have bred separately for more than 100,000 years.

The fact that there is no continuing (surviving) chain of infection from any of the hundreds of HIV infections that cut hunters and butchers (presumably) got from chimpanzees in past centuries tells us that humans who got HIV before 1900 were more likely to die than to pass it on to other humans. In other words, before 1900, HIV transmitted too slowly through sex to spread any of these infections into an epidemic.

In The Origins of AIDS,[12] Jacques Pepin identifies the post-1900 introduction of injections into Central Africa as the change that allowed HIV to spread. Peter Piot, the long-time former head of UNAIDS concurs:[13]

…Pepin suggests that the efficiency of sexual transmission of HIV-1 was too low to enable the virus to spread beyond a few individuals. He then shows how mass campaigns organized by French and Belgian colonial administrations to treat tropical diseases such as yaws, sleeping sickness, leprosy, syphilis, and malaria exposed hundreds of thousands of people to intravenous or intramuscular injections with potentially contaminated needles and glass syringes… As far as the origins of AIDS are concerned, unless some completely new evidence emerges, it will be difficult to come up with a better explanation than Pepin’s.

If Pepin and Piot are correct, all HIV infections in the world come from unsafe health care in Africa, if not immediately and directly, then at earlier points in the chains of transmission from cut hunters and butchers to all current infections.

[1] Attributed to Albert Einstein, but disputed

[2] In countries with more than one survey, I report data from the latest survey. Source: ORC Macro. Service Provision Assessment Surveys as follows: Kenya 2004; Namibia 2009; Rwanda 2001; Rwanda 2007; Tanzania 2006; Uganda 2007; Zambia 2005. Calverton, Maryland: ORC Macro, various years. Available at: (accessed 21 September 2012).

[3] Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006; 6: 130. Available at: (accessed 22 September 2012).

[4] Quote from p. 9 in: UNAIDS, Living in a World with HIV and AIDS: Information for employees of the UN system and their families. Doc no: UNAIDS/04.27E, July 2004, revised December 2004. Geneva: UNAIDS, 2004. Available at: (accessed 12 January 2011).

[5] Quote from p. 23 in: WHO. AIDS and HIV infection: information for United Nations employees and their families. Doc no. WHO/GPA/DIR/91.9. Geneva: WHO, 1991. Available at: (accessed 22 September 2012).

[6] This condition is satisfied if 30% of adults get HIV from blood. If so, an adult has a 51% (=30% + 21%) chance to get HIV from blood (30%) or through sex with someone who got it from blood (21% =70% x 30%).

[7] As used in this note, “heterosexual sex” includes all insertive sex between men and women, including penile-vaginal and penile-anal sex.

[8] UNAIDS. 2010 Global Report. Geneva: UNAIDS, 2010. Available at: (accessed 22 September 2012).

[9] These 14 countries are: Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe in Southern Africa; Cameroon and Gabon in Central Africa; and Kenya, Tanzania, and Uganda in East Africa.

[10] Gisselquist D. Points to Consider: responses to HIV/AIDS in Africa, Asia and the Caribbean. London: Adonis & Abbey, 2008. This book is available for free download at:

[11] Vallari A, Holzmayer V, Harris B, et al. Confirmation of putative HIV-1 group P in Cameroon. J Virol 2011; 85: 1403-07.

[12] Pepin J. The Origin of AIDS. London: Cambridge University Press, 2011.

[13] Piot P. Ingredients for a perfect storm. Science 2011; 334: 1642-1643.

The African Circumcision Experiment: Donor Driven?

[go to or return to first circumcision page]

I have spent the last two weeks in the West of Kenya trying to get people’s views on mass male circumcision, what is called the ‘Voluntary Medical Male Circumcision’ (VMMC) program. I have written notes about my visit on my blog, HIV in Kenya, but I should summarize the main findings here as they are not difficult to summarize, and as male circumcision is a very important potential HIV risk in Kenya. I admit, it has been very hard to find ordinary people who will talk about the subject, though I have found some. But it hasn’t been so hard to get people deeply involved in the VMMC program to argue the case for circumcising millions of Africans. As I shall explain, the case is even weaker than I thought before coming here.

The main finding is that VMMC is driven by money, by donor funding. There are copious amounts of donor funding available for male circumcision, but there are is very little funding for healthcare, unsafe or otherwise, education, infrastructure, employment or any other area of development. Everyone involved in HIV, health, development, etc, needs to apply for donor funding and they know they are wasting their time if they apply for funding for things donors don’t currently place any emphasis on. Everyone knows that HIV projects get funding, but only certain kinds: these must presuppose that almost all HIV transmission is through heterosexual sex. Circumcision ticks all the boxes.

Another finding is that even the proponents of VMMC are not convinced by the evidence for the community level effectiveness of such a program. They accept that the evidence of partial protection gleaned from randomized controlled trials (RCT) suggests that the level of protection that can be expected at a community level may be very low; it may even be cancelled out by other factors that result in increased HIV transmission as a result of VMMC. However, they appear to agree that interventions that have been carried out so far, such as various types of (sexual) behavior change communication (BCC), has not worked very well. Some say BCC hasn’t worked at all.

Curiously, despite the agreed lack of effectiveness of BCC programs, those defending VMMC say that they are not proposing mass circumcision on its own; no, they are proposing VMMC plus BCC. When it is pointed out to them that a program that doesn’t work combined with a program that is unlikely to be very effective still equals yet more ineffective intervention, they tend to revert to the ‘what else can we do’ attitude, along with the argument that it is the donor who decides what gets funded. The most defeatist people I could find were the proponents of VMMC themselves. Most of them didn’t even seem convinced of its potential effectiveness at a community level, all they know is that they will get paid.

It’s been hard to find people who are less closely connected to VMMC to talk, particularly to be interviewed in front of a camera, which is something I have been trying to do. Some of them say they don’t beleive the program will have much effect. But some say they believe it will work. People tend to know that the operation does not claim to give 100% protection but they don’t realize that the 60% protection claimed from the RCTs does not equate with 60% protection at the community level. While 60% (or more, or less) protection is a difficult enough concept to explain, explaining the difference between RCTs and community level interventions is not so difficult; everyone knows that if you pamper people for a while you will get quite different results from when you round them up and squeeze them through some kind of industrial process (ie, VMMC).

We have been bombarded with claims about circumcision giving partial protection against HIV; what has not been so clear is that the evidence for partial protection is itself only partial (pun intended). We don’t know what 60% protection in an RCT would amount to at the community level. Worse still, we need to wait another 6 years to find out, because the 10 year program in Kenya is only in its fourth year. This is not so much a community level intervention as a community level experiment. The only people I’ve found who seem to be aware of this is the proponents of VMMC. Is it unfair of me to compare this to the Guatemala syphilis experiment, referred to by Barak Obama as a crime against humanity? Or is it more like the Tuskegee syphilis experiment, referred to by Bill Clinton as racist?

The victims of this kind of human experimentation without informed consent (people do not consent to being part of an experiment and they are not given adequate information about the risks of circumcision nor the level of protection against HIV they can expect, although that is not even known) are not just the Luo men and possibly infants who will be circumcised under the VMMC program. The sexual partners of those circumcised are also deceived about levels of protection and risk. And even Kenyans who already circumcise, for traditional or other reasons, are deceived about protection and risk involved where HIV and circumcision are concerned, although it does not target them, specifically. So why circumcision? Because the money says so.

For more on circumcision, see also Don’t Get Stuck’s male circumcision section.