Unsafe injections rejected as major source of HIV infection in Africa

A recent theory proposing that unsafe injections are a major cause of HIV-1 infection in sub-Saharan Africa is rejected by authors of an article in this week’s issue of THE LANCET.

During the past year, a group (D Gisselquist and colleagues) has argued that unsafe injections are a major mode of HIV-1 transmission in sub-Saharan Africa, with up to 40% of HIV-1 infections being attributed to unsafe injections. In this week’s issue of THE LANCET, an international group of experts* has identified and reviewed the main arguments used to question the conventional view that unsafe sex is overwhelmingly the leading mode of HIV-1 transmission. The authors state that although there is a clear need to eliminate all unsafe injections, epidemiological evidence indicates that sexual transmission continues to be by far the major mode of spread of HIV-1.

The authors base their conclusions on a number of observations. A major flaw in the Gisselquist theory, they state, is that in sub-Saharan Africa unsafe intramuscular injections (defined as the reuse of needles/syringes in the absence of proper sterilization) are not as frequent as alleged. Further, they state, needles and syringes are uncommonly contaminated by blood after use (and are rarely contaminated by HIV, even after use on HIV-positive individuals) and the common practice of washing and heating of reused needles and syringes efficiently destroys HIV. The authors also include arguments that HIV-1 infection in children (who are not sexually active) is uncommon, that patterns of injection use do not correlate well with HIV incidence, that individuals who are initially HIV-negative but at a later date are found to be HIV-positive do not have substantially different histories of injections than those who did not become HIV-positive, that association is not the same as causation, and that high rates of other sexually transmitted infections in Africa are compatible with frequent sexual transmission of HIV.

Lead author George Schmid from the World Health Organization (WHO) comments: “Analysis of studies published by Gisselquist and colleagues provides no compelling evidence that unsafe injections are a major mode of HIV-1 transmission in sub-Saharan Africa. We agree, however, that unsafe injections are an unacceptable practice and that efforts should be increased to reduce exposure of patients to any bloodborne infection in health-care settings.” The authors also noted that improved data are needed to identify these risks, and that research should focus not just on the formal health-care system (both public and private), but also on the informal health-care system, eg. practices of traditional healers. The authors concluded: “…epidemiological evidence indicates that sexual transmission continues to be the major mode of spread of HIV-1 in Africa.”

*Institutions of authors: World Health Organization, Geneva; United Nations Joint Programme on AIDS, Geneva; Institute of Tropical Medicine, Antwerp; Joint Clinical Research Centre, Kampala; Imperial College, London; London School of Hygiene and Tropical Medicine, London; Centers for Disease Control and Prevention, Atlanta, GA; Harvard School of Public Health, Boston, MA; Yale University School of Medicine, New Haven, CT.

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