 Good treatment is vital in Africa's HIV-prevalent areas and parents should not be scared of taking their children to the doctor |
Nurse Filipa Caetano Peres, (left) Mozambique, 2001. Photo by Gideon Mendel. She says: "My job involves working with the doctors here at this clinic (in Mozambique) which specialises in caring for people who are sick with HIV or Aids. It is called Bem Vindo, meaning 'welcome'. The main problem I face in this clinic is people's fear about telling their families and partners. Most say: 'If I tell my family they will discriminate against me'. Women say: 'If I tell my husband he will chase me away'. Men say: 'If my wife finds out she will leave me'. When people have the HIV virus, the body is sensitive to any type of disease, so we do our best to treat opportunistic diseases and often people get much better. I explain about the kind of behaviour they should have once they are HIV positive, like using condoms to avoid spreading the diseases. Many of our patients say they like the clinic. We help them put on weight. We give them vitamins and food supplements and recommend the right food."
The African HIV epidemic - caused by sex - or dirty needles? Gus Cairns explores a recently reopened controversy
How did HIV come to afflict Africa so much more than other parts of the world? Is the ferocious spread of the virus at least partly due to unsafe medical practices, such as using unsterilised needles for injections, rather than sex?
The controversy has now been reopened by the publication of three papers in the International Journal of STDs and Aids. The three main authors, two STI doctors, David Gisselquist and John Potterat, and medical psychologist Stuart Brody have in the past questioned the importance of vaginal intercourse in spreading HIV in the USA. What is new in the latest papers are the extraordinary figures they estimated for the proportion of HIV spread by unsafe medical practices in Africa - anything from 45 to 65 per cent of cases.
They are not saying HIV never spreads via vaginal sex; clearly it does. "But," says David Gisselquist when I interview him in London, "not fast enough to sustain an epidemic."
If the additional reason for this explosive HIV growth is unsterilised needles, then Africa is still partly in the grip of a needle-driven epidemic like Russia's, but far bigger - and one of the most tragic accidents in medical history.
 David Gisselquist |
How has HIV grown so fast?
David Gisselquist says: "When you're looking at HIV doubling in a year, as it
has done in some African countries, you have a hard thing to explain if you think
it's due to vaginal sex. This is additionally a problem in countries like Zimbabwe
where STI rates were actually falling as the HIV rate was climbing. And it can't
be simply due to a 'time lag' effect - people caught the STIs last week, but they
caught HIV two years before testing - because the attrition rate in Africa due
to Aids is so high you need ongoing transmission in order to sustain high prevalence.
"The few African studies that have been done show heterosexual infection rates between couples no higher than in the West. And when we looked more closely at those studies and measured the risk factors for people who became positive within a specific year, it was only 15 per cent more risky to have had multiple sexual partners rather than just one. When you asked the same question about having injections, the additional risk averaged at 28 per cent. So having an injection is twice as risky as having several partners."
Dated data
An 'injection culture' certainly prevails in Africa - people get jabs instead
of pills. But Gisselquist's paper has one obvious flaw. It is based entirely on
an analysis of studies of HIV prevalence or new diagnoses in Africa pre-1988.
He explains this is because what he was trying to do was look at the assumptions
made when the WHO first issued its estimates of HIV causation in Africa around
this time.
In particular he cites a paper by UNAIDS Founder Jonathan Mann among others, which in 1988 estimated that 80 per cent of African HIV was due to heterosexual sex, 11 per cent due to mother-to-child transmission, six per cent due to blood transfusions, and no more than two per cent each due to sex between men and unsterilised needles.
The studies Gisselquist reports certainly show that having injections was one of the biggest predictors of having HIV back in '88, from centres varying from Tanzania to Zaire. But so was visits to prostitutes or having had an STI.
He also makes one very questionable assumption. If HIV is higher in urban areas - and it is - it may be because people are having more medical care and therefore more injections, he says. But equally, urban areas are also going to have better standards of medical safety - a factor he discounts.
Anyway, might positive people have had more injections because they were ill with HIV-related symptoms?
"But people could be going to a clinic, getting antibiotics for STIs - and getting HIV with the needle," says Gisselquist.
As well as denial due to homophobia, there could also be a vast amount of unacknowledged anal sex going on. It's not after all unknown as a method of preserving virginity in some societies.
Gisselquist replies that Brody and Potterat are addressing this very question in their next paper, due to be published in June.
The mystery of the positive children
Gisselquist has a few other answers to people who think his 1988 data cannot be
a guide to what's happening today. He cites last year's survey by the Human Sciences
Research Council (HSRC) of South Africa. This, sponsored by Nelson Mandela's foundation,
was the first attempt at a nationwide survey of HIV prevalence, over all ages.
It found disturbingly high HIV rates not only where you'd expect them but also
where you wouldn't. In the white population, for instance (six per cent). In children
aged 2-14 (5.6 per cent). And in white children, where the HIV prevalence was
a startling 11.3 per cent. Statistically insignificant though: 16 HIV positive
white children out of a total of 8,500 people surveyed.
But Gisselquist still says that 5.6 per cent of HIV positive children couldn't possibly all result from transmission from the 12.8 per cent of HIV positive women: "If you do the sums, 75 per cent of HIV in South African children is unexplained." And yes, he has thought of child sex abuse: "While child rape is a terrible criminal problem in South Africa, only one per cent of children it had happened to in Cape Town became HIV positive."
He also cites studies on teenagers. "In Carltonville, South Africa, girls aged 17-19 years old who had only had 1.2 sexual partners on average, ever, were 20 per cent HIV positive.
He finishes with a comparison with the USA. "There are 400,000 people with HIV in the US. Most have it through anal sex or drug injecting. Only 10,000 probably have it through penile/vaginal sex.
"I admit that what we're proposing is a speculation. But the first estimates were speculations too - which have never been proven."
 Catherine Hankins |
'They haven't thought about the impact'
None of this washes with Catherine Hankins, the Chief Medical Officer at UNAIDS.
"We all agree medical safety should be on the agenda," she says.
"But I think these guys are completely unaware of what their impact might be in Africa. A woman is trying her best to get her man to use condoms and to get immunisations and medical care for her child. How's she going to react if she's told condoms may not be necessary, but is scared off taking her kid to the doctor?
In any case, she says, Gisselquist's arguments don't stand up.
"We estimate that 25 per cent of injections in Africa are unsafe. But in Asia 50 per cent are unsafe. There's a much bigger culture of getting vitamin shots from a stall in the marketplace there. Why didn't Asia get the big epidemic first?"
The impact of STIs
The difference between the two continents, Hankins says, may lie "in the fact
that Asia has way lower STI rates than Africa." And she cites recent studies that
show that it is not the 'classic' STIs that make people much more infectious,
and infectable, with HIV. It's the 'hidden', asymptomatic ones: HPV (genital wart)
virus and, in particular, asymptomatic herpes.
The other thing you'd expect if most of HIV in Africa were caused by needles is lots of hepatitis C to go with it. Hankins insists: "Everywhere where drug users have high rates of HIV, they have even higher rates of hepatitis C. But in South Africa the rates are 20 per cent and 0.1 per cent, respectively.
"There's also the evidence from medical needlestick accidents. In cases where medical personnel accidentally spiked themselves with HIV-contaminated needles, the infection rate was 0.33 per cent - one in 300."
The South African HSRC study she regards as flawed. "They used an oral HIV saliva test, and there was no checking for cross-contamination, to see if household members weren't swapping sample sticks."
But even with STIs, how do you account for the extraordinary difference in heterosexual prevalence?
 Photo: © A. Crumb, TDR, WHO/SCIENCE Photo Library |
As Hankins surmises, in some cultures what you do with your sexual partners over time is different. In the West we tend to be serially monogamous. In Africa, if you've had sex with someone at some point, the door isn't considered closed on picking up on that relationship again.
"Take a middle-class African businessman. He has had five women - nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a 'deuxième bureau' - a mistress who might have had his child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.
"Within a year he may have infected four other women. Now, if I've had five sexual partners and catch HIV from the fifth, as a western woman I'm unlikely to return to the other four and infect them!"
Hankins also refers to studies of prostitutes in Nairobi which have shown time and again that if clients got an STI from a prostitute with HIV they were at least twice as likely to get HIV at the same time than if they didn't catch an STI.
"And lastly, there's the factor of bad nutrition, and low immune status cause by pre-existing diseases like TB and malaria," she adds. Her final response is:
"Yes, it's unethical that 30 per cent of injections in the world are unsterilised. But it takes maturity to understand how to present prevention arguments to the people that need to hear them."
