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93% of South African Maternity Wards Unsafe for Mothers and Babies

Despite the constant claim from UNAIDS and the HIV industry that HIV is almost always transmitted through unsafe heterosexual sex in African countries, though nowhere else in the world, it has yet to be demonstrated how appalling conditions in hospitals in high HIV prevalence countries hardly ever result in HIV and other serious diseases being transmitted. After all, relatively unsafe conditions in Western countries have resulted in incidents of healthcare transmitted HIV on numerous occasions. TB has been transmitted in hospitals in South Africa. So why not HIV and other bloodborne diseases?

A recent audit carried out in South African hospitals found that 93% of maternity wards are not safe for mothers or babies. This is no surprise to people who have frequently commented on the fact that HIV prevalence is often higher among women who give birth in health facilities than it is among women who give birth at home. But South Africa has the highest HIV positive population in the world. Do UNAIDS and the HIV industry really want to stick to their contention that these conditions hardly ever result in HIV transmission?

In the past, UNAIDS’ response has been that they would prefer to see people attending health facilities, as it is better for their health. But there is a lot of evidence that health facilities are not safe places. Even the UN itself has issued guidance to their own employees to carry their own medical equipment when working in high HIV prevalence countries, as safety in health facilities can not be guaranteed unless they are ‘UN approved‘. So they can’t have it both ways: if health facilities are unsafe for UN employees, they are unsafe for South Africans.

In the absence of any other explanation, I would suggest that UNAIDS and the HIV industry exhibit a profound form of institutional racism and sexism (because far more women are infected with HIV than men). I could be wrong and the industry may have the best interests of South Africans at heart. But if that’s the case, why is almost all the industry’s literature about sexual behavior and a few other things considered to be illicit or even illegal, such as intravenous drug use, male to male sex and commercial sex work?

HIV transmission through contaminated blood is extremely efficient, which is why intravenous drug use is so dangerous. But the highest use of syringes and other skin piercing instruments is found in health facilities (and also in traditional medicine practices, pharmacies, hairdressers, tattoo parlors and various other contexts to which UNAIDS and the industry appears to be completely blind). Hundreds of millions of injections are given every year; the majority are either unnecessary or the treatment could be administered non-invasively.

Apparently the maternal mortality rate is a massive 310 deaths per 100,000 live births in South Africa. In addition to threatening the lives and health of mothers, these conditions threaten the lives and health of babies and young children too. People are not made aware of the dangers of hospital transmitted infections. And what hospital transmitted infection could be more of a risk in extremely high prevalence areas than HIV? The virus tends to be far more common in built up areas, close to main roads and hospitals. In contrast, it tends to be a lot less common in more rural and isolated areas.

Yes, people need accessible healthcare, but no, not at all costs. If healthcare is unsafe, as it clearly is in South Africa and many other African countries (where conditions can be so bad that most people don’t use health facilities, and HIV prevalence is a lot lower), this will not reduce the transmission of HIV or other diseases. The worst place to go if you want to avoid a transmissible disease is a hospital if conditions there are as bad as they are in most African countries. Indeed, some epidemics, such as ebola, have hospitals as their epicenter, and the epidemic is only stopped when the hospital is closed.

This is not to say that all health facilities are dangerous, though the majority of them seem to be in South Africa. Nor is it to say that all healthcare workers could be doing more harm than good, though a lot seem to be doing harm in South Africa. Congratulations to the country on publishing the report, but it won’t do anyone any good until people are aware of the risks they face, and especially of the fact that HIV is not always transmitted sexually. Some of the worst HIV epidemics were almost definitely started by unsafe healthcare practices. How do we know that these same practices are not still contributing to some of the worst epidemics?

Out of 3,880 hospitals audited, some other findings include:

  • Only 32 of the facilities audited complied with infection prevention and control;
  • Only two facilities could guarantee patients’ safety;
  • Just 161 facilities were clean enough to meet the audit’s tough standards; and
  • Staff attitudes towards patients were awful – just 25% of staff in clinics were found to embody positive and caring attitudes

It’s time to stop treating South Africans and other Africans as if they are somehow different from non-Africans, as if their sexual behavior is almost uniquely dangerous, as if everyone who is HIV positive must have engaged in some kind of illicit behavior. People need to know that hospitals are dangerous places so they can take steps to avoid being infected with HIV, TB, hepatitis or any other disease while in hospital. That means UNAIDS and the HIV industry need to give up their obsession with ‘African’ sexuality, sexual behavior and sexual mores. It’s not all about sex, so let’s act accordingly.

10 years later: Continuing unethical and incompetent behavior by medical professionals coincides with conflict of interest, leading to millions of unexplained HIV infections

Health care professionals in African ministries of health, the World Health Organization (WHO), donor organizations, and foreign universities participating in HIV-related research in Africa know the proper response to unexpected HIV infections (eg, in children with HIV-negative mothers, in spouses with one lifetime HIV-negative sex partner). That response is to find the source of the infection by tracing and testing others who attended suspected hospitals and clinics, and thereby to identify and correct unsafe practices to protect other patients. There have been no such investigations of unexpected HIV infections in any country in sub-Saharan Africa.

Health care professionals are ethically obligated to give patients accurate information about risks. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient[1] states: “A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions…” and “Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services.”

Medical researchers trying to find what is different about HIV transmission in Africa that could explain the world’s worst HIV epidemics know that the best way to do so is to trace and test sex and blood contacts when someone shows up with a new or unexplained infection. Unfortunately, medical researchers (who are also health care professionals) have been reticent to find their colleagues’ contribution to Africa’s HIV epidemics. For example, 44 studies[2] that followed more than 120,000 adults in Africa and observed more than 4,000 new HIV infections linked only 186 (4.6%) of those infections to HIV-positive sex partners, all of which were spouses the study had been following all along. No study traced and tested any sex partner (spouse or other) not already included and followed in the study. No study traced blood contacts, and few studies reported any information about blood risks. Despite lack of evidence (avoided and ignored evidence) all studies assumed infections came from sex. (These 44 studies were randomized controlled trials of interventions to prevent HIV in African adults.)

For 30 years, medical professionals have accused HIV-positive Africans of careless or immoral sexual behavior. But if one looks for what is different in Africa vs. the US and Europe, what jumps out is not sexual misbehavior but rather unethical, immoral, and incompetent behavior by health care professionals: not investigating unexpected HIV infections; not warning the public about unsafe health care; and mismanaging research so as not to find risks for HIV.

Ten years ago, on 14 March 2003, WHO held a one-day meeting to discuss the role of unsafe medical injections in Africa’s HIV/AIDS epidemics. WHO staff arranged the meeting after a series of articles[3][4][5] in the International Journal of STD & AIDS during 2002-03 called attention to decades of overlooked evidence that unsafe health care infected Africans with HIV. The 20 invited attendees[6] included three co-authors of these articles (Brody, Gisselquist, and Potterat).

WHO staff managed the meeting as part of a continuing cover-up of hospitals’ and clinics’ contribution to Africa’s HIV epidemics. The meeting was closed to the public. A first press release, prepared by WHO staff in the days before the meeting and released before it ended, misleadingly claimed:[7] “An expert group has reaffirmed that unsafe sexual practices are responsible for the vast majority of HIV infections in sub-Saharan Africa…”

Later that year, WHO’s meeting summary[8] acknowledged that “No consensus emerged from the conference” on whether “sexual transmission was responsible for the large majority of HIV infections.” The summary also noted “universal agreement…that better data on the possible role of unsafe injections, and other health care practices, in HIV transmission are needed to more definitively determine their role in HIV transmission in sub-Saharan Africa.”

Unfortunately, the events of the last 10 years show a continuing unwillingness on the part of too many health care professionals to do what is needed to find and stop HIV transmission through unsafe health care in Africa.

[1] World Medical Association. 2005. Declaration of Lisbon on the Rights of the Patient. Ferney-Voltaire, France: WMA. Available at: (accessed 18 August 2012).

[3] Gisselquist D, Rothenberg R, Potterat JJ, Drucker E. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. By: Int J STD AIDS 2002; 13: 657-666. Available at:

[5] 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:

[6] WHO. Unsafe injection practices and HIV Infection. Meeting summary (14 March 2003 meeting, undated summary posted by WHO later in 2003). Available at: (accessed 6 January 2013).

[7] WHO. Expert group stresses that unsafe sex is primary mode of transmission of HIV in Africa. Media Center statement 14 March 2003. Available at: (accessed 6 January 2013).

[8] WHO. Unsafe injection practices and HIV Infection. Meeting summary (14 March 2003 meeting, undated summary posted by WHO later in 2003). Available at: (accessed 6 January 2013).

UNAIDS Getting to Zero: Zero Lies, Zero Double Standards and Zero Institutional Racism

According to George Ochoa “An infection spread by unsafe injection practices can happen anywhere” and finds that “Since 2001…at least 48 outbreaks caused by unsafe injection practices have occurred in the United States, with the majority (90%) in outpatient settings (10 in pain clinics and nine in oncology clinics). Twenty-one of the outbreaks involved hepatitis B or hepatitis C; 27 were bacterial. More than 150,000 patients required notification to recommend bloodborne pathogen testing following exposure to unsafe injections.”

But if UNAIDS is right, George Ochoa is wrong; HIV infections through unsafe injection hardly ever occur in high HIV prevalence countries, which are mostly in sub-Saharan Africa. That must explain why, since the HIV epidemic began 30 years ago, no outbreak investigations have been carried out in sub-Saharan Africa.

UNAIDS’ ‘Kenya Aids Epidemic Update 2011’ briefly mentions re-use of injecting equipment during immunization programs (which account for a small percentage of all injections administered). They say “In a study of young men (ages 18–24) in Kisumu, men who received a medical injection in the last six months were nearly three times more likely to be HIV-positive”.

However, the report also claims that a minuscule percentage of HIV infections were a result of any kind of unsafe healthcare and that “Sexual transmission accounts for an estimated 93% of new HIV infections in Kenya, with heterosexual intercourse representing 77% of incident infections. Adults in stable, seemingly low-risk heterosexual relationships make up the largest share of new HIV infections.”

Did they assess the non-sexual risks faced by those people in ‘seemingly low-risk’ relationships? The report says “Among adult participants in the 2003 Kenya Demographic and Health Survey who said they had “no risk” for HIV, nearly 1 in 20 (4.6%) were in reality HIV infected”. The implication is that all those people were infected sexually, but they just didn’t realize they were at risk. For the authors of the UNAIDS report, the people in question were either stupid, liars or stupid liars.

The report recognizes that if there is a large number of HIV positive people in the population, the risk for each sex act is higher. But they don’t acknowledge that the same circumstances also make the risk of infection from an unsafe injection or other skin piercing procedure far higher. HIV prevalence is about 10 times higher in Kenya than it is in the US. But there have been no reported outbreaks of HIV or any other disease as a result of unsafe healthcare in Kenya or any other sub-Saharan African country.

Another study, by WHO, says that “around half the injections used across the world are unsafe for administration, with a worse ratio in developing countries”. So is it possible that George Ochoa is right in stating that “An infection spread by unsafe injection practices can happen anywhere”, and UNAIDS wrong? Well, shocking as it may seem to those who look to UNAIDS as an institution that specializes in HIV, what they say to Africans is different from what they say to UN employees.

Here’s what they have to say to UN employees: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections.

They also say: “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. 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.

I don’t know about anyone else, but I tend to believe the warning they give to UN employees, but that suggests they are lying about the risk that Africans face from unsafe healthcare. Why would this august institution lie about a very serious risk of HIV infection in the highest HIV prevalence countries in the world? Well, I can’t answer that question. If it’s vital to warn UN employees, it should be vital to warn those who don’t actually have much choice about which health facilities to use, UN approved or otherwise.

UNAIDS’ current touchy-feely campaign is called ‘Getting to Zero: zero new infections, zero discrimination, zero Aids related deaths’. How about ‘zero lies, zero double standards and zero institutional racism’ as an alternative set of objectives?

WHO Acknowledges HIV Risk in Ugandan Hospitals?

I know infection control professionals are not common in African countries but I hadn’t realized that up till recently there were none at all in Uganda. I wonder how many there are in countries that have received only a fraction of the funding Uganda has received, especially HIV funding. A WHO article about their ‘African Partnerships for Patient Safety’ initiative announces that one hospital, seven hours drive from the capital city, now “has its own infection control professional, the first in the country”. The article proudly states that “just two years ago, patient safety was an obscure concept that was almost impossible for hospital staff to apply when faced with practical realities”.

Could this be the same WHO that tells us that the vast majority of HIV infections in Uganda are a result of unsafe sex? True, the fact that patient safety was an ‘obscure concept’ does not mean that HIV transmission through unsafe healthcare is common. Rather, it means that we, WHO included, have no idea whether such transmission is common or not. We don’t know what proportion of HIV transmission is a result of unsafe healthcare and, therefore, what proportion is a result of the WHO’s beloved sexual transmission. Not that this stops WHO, UNAIDS and others from droning on about African sexual practices, ‘dry sex’, concurrency, circumcision, widow inheritance, long distance truckers, commercial sex workers and the rest, as if that’s all there is to HIV epidemics where many of the people infected face little or no obvious sexual risk.

The most striking thing about the official Modes of Transmission Survey for Uganda is that the largest group contributing to new infections consists of people in stable heterosexual couples. In many of those couples the index partner, the one infected first, is female (fewer males are infected but there is equally little evidence that they were all infected through unsafe sex). As the first to be infected, these women could not have been infected by their partners. So how were they infected? According to UNAIDS and WHO thinking, they must have had sex with someone other than their partner. The UN’s IRIN news service refers to them as ‘cheaters’, which is a reflection of IRIN’s typical style and level of sensitivity. But can the Modes of Transmission Survey rule out non-sexual transmission of HIV through unsafe healthcare, traditional and cosmetic practices in this group of people who face such low sexual risk? The simple answer is ‘no’. For UNAIDS, WHO and other institutions, it is simply taken for granted that the bulk of transmission is through unsafe sex. Questions about non-sexual risks are rarely raised and peremptorily dismissed if mentioned.

Survey after survey shows that those who engage in unsafe sex are no more likely to be infected that those who don’t; often, those who don’t engage in unsafe sex are more likely to be infected. High HIV prevalence does not tend to cluster in isolated areas, except where there have been major health programs. It does tend to cluster among wealthier, better educated, more mobile, employed people who are close to major transport routes and close to or in major cities; coincidentally, they also tend to be much closer to health facilities. Is one infection control expert in an isolated hospital in Uganda going to make much difference to transmission rates? Possibly in that hospital. But it is the initial assumption made by WHO, UNAIDS, etc, that needs to change: knowing someone’s HIV status tells you nothing about their sexual behavior and knowing about their sexual behavior is not a good predictor of their HIV status.

That may sound counter-intuitive if your ‘intuition’ is based on reading mainstream press, and even much of the more specialized scientific literature. HIV in African countries is almost invariably associated with sexual behavior. In Western countries this is not the case. HIV in wealthier countries tends to be attributed to intravenous drug use and male to male sex. Even in Asian countries, people are sometimes given a little benefit of doubt; they may have been infected through unsafe healthcare. But in African countries with the worst epidemics, there has never been an investigation into healthcare practices; there has never been an investigation into why so many women in Uganda (for example) are infected when their husbands are not, and where these women did not face any other obvious risks; there has never been an investigation into why so many babies are infected when their mothers are not; in fact, what proportion of babies are infected whose mothers are not? We don’t know the answer to these questions we appear not to even want to ask.

Does the ‘African Partnerships for Patient Safety‘ indicate an admission that patient safety could be a factor in some of the world’s worst HIV epidemics, after thirty years of insisting that HIV is all about sex and wasting billions of dollars accordingly, or is it mere lip service? I won’t be holding my breath.

Maternal Health Care a Significant HIV Risk in Ethiopia

[Cross-posted from the HIV in Kenya blog.]

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I’d like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It’s not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various ‘initiatives’ aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting ‘cheaters’. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be ‘cheaters’ could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It’s certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don’t know they are infected. It must also be remembered that most people don’t realize that there are significant non-sexual risks; if they don’t know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people’s worries in countries like Ethiopia, but only because many people don’t attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don’t Get Stuck With HIV site.]

Circumcision: a Case of Retributive Healthcare?

[Cross-posted from the HIV in Kenya site.]

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because “there is no guarantee of the proper sterilization of such materials.” UN employees are also reassured that “We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment.”

The US Centers for Disease Control (CDC) states that “Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States.

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

  • 230,000 HIV Infections
  • 1,000,000 Hepatitis C Infections
  • 21,000,000 Hepatitis B Infections
  • The above resulting in 1,300,000 deaths each year (WHO figures)
  • Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
  • At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force ‘healthcare’ in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of ‘retributive healthcare’.

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).