Recent claims by a group from the United States and Germany
that most HIV infection in Africa is transmitted by non-sexual routes are
potentially important. The
conventional view has been that 90% of transmission is sexual, but the new
studies have suggested that reported sexual behaviour and cross infection rates
in Africa could not explain the extraordinary spread of the epidemic there.
If so, there must be another major cause.
The most plausible is needle stick injuries, either from non-sterile
syringes or traditional scarification practices.
The debate has raised passions because many experts fear that publicity
will weaken the simple public health advice to “wear a condom”.
Last week Brody and
colleagues added to their case with an article in the BJOG
(British Journal of Obstetrics and Gynaecology) (6 May 2003).
They drew attention to a recent large survey in South Africa which showed
an HIV prevalence in children of twice that previously reported, and where a
high proportion of an albeit small and possibly biased sample appeared to have
no HIV infected parent. The
hypothesis is eminently testable. The
finding of HIV positive children with HIV negative parents needs replicating,
and HIV contaminated needles awaiting reuse should be looked for in corner
chemists and such places.
In the meantime, and whatever the precise percentage, it
seems incontrovertible already that the proportion of non-sexual transmission is
higher than was previously thought.
The public health message needs updating.
Keep it simple for people crazed by lust - “wear a condom”, but
expand it for those in calmer moments – “avoid needles without good reason
and ensure they are sterile”.
African health workers must also guarantee that their
needle sterilisation systems are beyond reproach.
If Brody and his colleagues are even half right, future generations in
Africa will not forgive those doctors who fail to alert people properly to the
dangers of needle stick injuries.
The following is from Brody's press release
Dr Stuart
Brody of the Institute of Medical Psychology and Behavioural Neurobiology,
University of Tübingen, Germany and colleagues
estimate 670,000 children aged 2-14 years in South Africa are HIV-infected. They
suggest this is almost three times larger than conventional estimates for
mother-to-child infection.
A previously
published study carried out by the Human Sciences Research Council (HSRC) of
South Africa revealed an HIV prevalence of 5.6% among 2–14 year olds. An
observation from the same survey noted that white children had an HIV prevalence
of 11%, while white adults had one of 5.7%, pointing to an important role for non-mother-to-child
transmission.
Dr Brody and
colleagues reject the hypothesis that childhood sexual exposure is responsible
for such a high incidence of HIV-infection. They comment that sexual experience
in this age group is low (less than 2% of under 15 year olds) and that despite
media coverage of infected men seeking virgin girls as a ‘cure’ for their
HIV infection, few cases have been documented.
They suggest a
more reasonable hypothesis, supported by other evidence, is that children are
infected through non-sterile medical procedures. Dr Brody writes: “Not only
are injections popular among African patients, administered at an estimated 90%
of medical visits, but also often unnecessary, and injection equipment is often
reused without sterilisation.” He concludes that: “The common belief that
90% of HIV transmission in Africa is driven by heterosexual exposure is no
longer tenable.” And adds that doctors: “… must educate their patients in
the dangers of non-sterile injections and ensure that their own practice is
beyond reproach.”
For
Further Information Contact the Author:
Dr Stuart
Brody, Institute of Medical Psychology and Behavioural Neurobiology, University
of Tübingen, Germany on email: stuartbrody@hotmail.com
