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    Friday, February 21, 2003

    Sex, AIDS, and Africans: A new study suggests that the African AIDS epidemic is from poor medical hygiene (i.e. reusing needles for injections) more than sexual promiscuity:

    Research published by US experts indicates that the spread of HIV infections in Africa may be more closely linked to unsafe medical care than previously thought.

    The report challenges widely held scientific views on the spread of the virus that can cause Aids.

    It estimates that two-thirds of the people with HIV in Africa become infected mainly through contaminated needles rather than through sexual contact.

    The UNAids organisation disputes the findings, and says there have not been adequate studies to support the conclusions that are drawn.

    My very first thought when I read this was, “My God! Medical professionals reuse needles in Africa?” My second thought was, “Why would any organization object to the findings?” It’s much easier to provide clean needles than to change people’s sexual behavior.

    Then, I read the study. It turns out that the crux of its argument is that before 1988, when the public health community adopted a consensus opinion that AIDS was transmitted in Africa mostly through heterosexual sex, there was plenty of statistical evidence that the HIV epidemic in Africa was caused by dirty medical needles. That evidence, according to the authors, was not only ignored, but suppressed by the world public health community:

    First, it was in the interests of AIDS researchers in developed countries—where HIV seemed stubbornly confined to MSMs [homosexuals - ed], IDUs [IV drug users -ed], and their partners—to present AIDS in Africa as a heterosexual epidemic; ‘nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS’ ... In a prominent 1988 article in Science, Piot and colleagues generalize with arguably more public relations savvy than evidence that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’. Second, there may have been an inclination to emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing programmes and efforts to curb Africa’s rapid population growth. Third, ‘the role of sexual promiscuity in the spread of AIDs in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans’, as Packard and Epstein document in a regrettably ignored 1991 article. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—eg, to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’ . In short, tangential, opportunistic, and irrational considerations may have contributed to ignoring and misinterpreting epidemiologic evidence.

    That’s pretty strong stuff. The authors are charging that WHO and other public health groups ignored the evidence of an easy solution to stemming HIV spread because of their preconceived notions about Africans - that is, their prejudices.

    Some of the highlights of the study:

    HIV and STDs: According to the authors' data, African HIV did not follow the pattern of sexually transmitted disease (STD). In Zimbabwe in the 1990s HIV increased by 12% a year, while overall STDs declined by 25% and condom use actually increased among high-risk groups.

    Infection rate: HIV spread very fast in many countries in Africa. For the increase to have been all via heterosexual sex, the study claims, it would have to be as easy to get HIV from sex as from a blood transfusion. In fact, HIV is much more difficult than most STDs to transmit via penile-vaginal sex.

    Risky sex? Several general behaviour surveys suggest that sexual activity in Africa is not much different from that in North America and Europe. In fact, places with the highest level of risky sexual behaviour, such as Yaounde in Cameroon, have low and stable rates of HIV infection. "Information…from the general population shows most HIV in sexually less active adults" .

    Children and injections: Many studies report young children infected with HIV with mothers who are not infected. One study in Kinshasa kept track of the injections given to infants under two. In one study, nearly 40% of HIV+ infants had mothers who tested negative. These children averaged 44 injections in their lifetimes compared with only 23 for uninfected children.

    Good access to medical care: Countries like Zimbabwe, with the best access to medical care, have the highest rates of HIV transmission. "High rates [of HIV] in South Africa have paralleled aggressive efforts to deliver health care to rural populations".

    Riskier to be rich: Most STDs are associated with being poor and uneducated. HIV in Africa is associated with urban living, having a good education, and having a higher income. In one hospital in 1984, the rate of HIV in the senior administrators was 9.2%, compared with the average employee rate of 6.4%.

    The authors conclude:

    At issue in a reevaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic.

    At the very least Africans deserve what even Western junkies are provided - clean needles. Maybe someone should set up a needle exchange program for African healthcare providers.

    UPDATE: A reader who once practiced medicine in Africa sends the following:

    I worked four years in two African countries twenty years ago. Let me tell you the facts.

    One, many untrained or minimally trained people set themselves up in practice, including traditonal healers. In our area, the N'gangas and the local anti government guerllas would give penicillin shots, and vitamin B shots. This was before HIV waas recognized, of course. I suspect even today a lot of people get shots from these folks, or other treatments (see below) instead of going to a clinic. Needless to say, they don't sterilize needles.

    Second, our clinics "sterilized" needles over a coleman type stove, boiling water, not a autoclave. Our clinics were run by people with 7-10 years of school and four years medical assistant training. They tried hard, but I don't guarantee they sterilized everything properly.

    Third, although we were rich enough to use sterile needles each time, we often reused the same syringe over and over. Glass syringe, of course, and took the needle from a metal autoclaved box where they were lined up one by one.

    We rewashed dressings: If they were very dirty, we burned them, but the parts that weren't touching skin we redressed. But a wound from the outside would often come in dressed with a rag. And we were rich: I usually had gloves, (read the first chapter of When the band played on, where the doctor did not have gloves)

    Finally, traditional medicine treated pain with "muti cuts". We could always tell where it hurt, because there were shallow cuts where herbs had been rubbed in. It's similar to moxification, i.e. counterirrtant therapy for pain. The local women often had scarification for cosmetic reasons. They made shallow cuts, used some herb, and had lovely decorations of keloid tissue on their abdomens. I doubt any of these knives were sterilized.

    We DID see syphillis and other STD's back then. But not at the rate that one sees HIV nowadays. Genital sores increase transmission, of course, but most cases came from the cities, so I suspect some cases are indeed due to partially trained people giving shots.

    In other words, don't blame the hospitals and clinics. Blame poverty.

    She brings up a point that I didn't make clear enough in the post, and which the researchers also mention in their paper - a lot of healthcare in Africa is done by people with little training. Of course poverty is the reason they reuse needles, but you would think that providing disposable needles and educating the people who use them would be a priority of the same international aid organizations that provide the medications and the immunizations.


    posted by Sydney on 2/21/2003 05:57:00 AM 0 comments


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