Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections

Práctica de inyecciones seguras por parte del personal de la salud: revisión integrativa

Introducción: Las prácticas de inyecciones seguras han recobrado importancia en las últimas dos décadas, como consecuencia de las infecciones asociadas con su aplicación incorrecta. Objetivo: Analizar la evidencia disponible sobre las prácticas de inyecciones seguras ejecutadas por el personal de la salud en su práctica clínica. Método: Revisión integrativa de la literatura, realizada en 12 bases de datos entre 1999 y 2018. Resultados: Se seleccionaron 29 artículos y se identificaron prácticas riesgosas como el reúso de los dispositivos de inyección en el mismo paciente o en otros, fallas en la técnica aséptica, ausencia o no seguimiento del protocolo posexposición, reencapuchado de la aguja y ausencia de inmunización contra el virus de hepatitis B. Conclusiones: Los esfuerzos orientados a la seguridad del paciente deben enfocarse también en acciones concretas dirigidas a la administración de los medicamentos.

Conflicting Views in Narratives on HIV Transmission via Medical Care

Molecular studies suggest that HIV arose in Africa between 1880 and 1940. During this period, there were campaigns by European colonial governments that involved unsterile injections of large numbers of Africans. That, along with other unsafe therapeutic interventions, may have propelled the evolution of HIV from SIV. Since subtype B in Africa may have been concentrated in white African homosexuals, it is possible that Westerners rather than Haitians introduced the virus to the New World. Amplification of HIV subtype B took place in Haiti, where transmission was facilitated by hazardous medical procedures including plasmapheresis. Representations in the media, however, largely ignore Western contributions to the spread of AIDS. This article focuses on the value of alternative narratives in fostering a balanced view that is less stigmatizing on developing nations.

Anal Intercourse Among Female Sex Workers in Côte d'Ivoire: Prevalence, Determinants, and Model-Based Estimates of the Population-Level Impact on HIV Transmission

Current evidence suggests that anal intercourse (AI) during sex work is common in sub-Saharan Africa, but there have been few studies in which the contribution of heterosexual AI to human immunodeficiency virus (HIV) epidemics has been investigated. Using a respondent-driven sampling survey of female sex workers (FSWs; n = 466) in Abidjan, Côte d'Ivoire, in 2014, we estimated AI prevalence and frequency. Poisson regressions were used to identify AI determinants. Approximately 20% of FSWs engaged in AI during a normal week (95% confidence interval: 15, 26). Women who performed AI were generally younger, had been selling sex for longer, were born in Côte d'Ivoire, and reported higher sex-work income, more frequent sex in public places, and violence from clients than women not reporting AI. Condom use was lower, condom breakage/slippage more frequent, and use of water-based lubricants was less frequently reported for AI than for vaginal intercourse. Using a dynamic transmission model, we estimated that 22% (95% credible interval: 11, 37% of new HIV infections could have been averted among FSWs during 2000-2015 if AI had been substituted for vaginal intercourse. Despite representing a small fraction of all sex acts, AI is an underestimated source of HIV transmission. Increasing availability and uptake of condoms, lubricants, and pre-exposure prophylaxis for women engaging in AI could help mitigate HIV risk.

The epidemic emergence of HIV: what novel enabling factors were involved?

Humans acquired retroviruses from simians, mainly through bushmeat handling. All epidemically successful HIV groups started to spread in early 20th century, contrasting with the antiquity of T-cell lymphotropic viruses, implying that novel enabling factors were involved in HIV emergence. Here we review the Parenteral Serial Transmission and the Enhanced Heterosexual Transmission hypotheses for the adaptation and early spread of HIV. Epidemic start roughly coincides in time with peak genital ulcer disease in cities, suggesting a major role for sexual transmission. Only ill-adapted and rare HIV groups emerged after approximately 1950, when injections and transfusions attained their maximal levels, suggesting that if parenteral serial transmission was necessary for HIV adaptation, it had to be complemented by sexual transmission for HIV to reach epidemic potential.

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Hepatitis C virus seroprevalence in adults in Africa: a systematic review and meta-analysis

With the introduction of more efficient treatments for hepatitis C virus (HCV), improved epidemiological information is required at the country level to allow evidence-based policymaking for elaboration of national strategies and HCV resources planning. We present a systematic review with meta-analysis of HCV seroprevalence data in adults in African countries. We conducted a systematic review of all HCV seroprevalence estimates reported in African countries from 2000 to 2014 in MEDLINE, AJOL and grey literature. We assessed studies performed in the general population and among blood donors, pregnant women and HIV-positive patients. A meta-regression analysis was used to provide adjusted estimates of HCV seroprevalence in the general adult population in each country, accounting for the heterogeneity in sample age structure and population types in the included studies. We identified 775 national-level estimations, among which 184 were included. Estimates of HCV seroprevalence were produced for 38 countries, in addition to the results from nationwide representative surveys available in Egypt and Libya. Next to Egypt, which clearly stands out, the highest levels of seroprevalence were found in Middle Africa (e.g. Cameroon, Gabon and Angola) and some West African countries (e.g. Burkina Faso, Benin), and the largest absolute numbers of infected adults were found in Nigeria, Ethiopia and Democratic Republic of Congo. This study exposes the diversity of HCV epidemiology among African countries. Egypt and several countries of West and Middle Africa present a HCV burden that will require strong governmental commitment to promote efficient preventive and curative interventions.

Cluster of HIV Infections Attributed to Unsafe Injection Practices--Cambodia, December 1, 2014-February 28, 2015

In December 2014, local health authorities in Battambang province in northwest Cambodia reported 30 cases of human immunodeficiency virus (HIV) infection in a rural commune (district subdivision) where only four cases had been reported during the preceding year. The majority of cases occurred in residents of Roka commune. The Cambodian National Center for HIV/AIDS (acquired immunodeficiency syndrome), Dermatology and Sexually Transmitted Diseases (NCHADS) investigated the outbreak in collaboration with the University of Health Sciences in Phnom Penh and members of the Roka Cluster Investigation Team. By February 28, 2015, NCHADS had confirmed 242 cases of HIV infection among the 8,893 commune residents, an infection rate of 2.7%. Molecular investigation of the HIV strains present in this outbreak indicated that the majority of cases were linked to a single HIV strain that spread quickly within this community. An NCHADS case-control study identified medical injections and infusions as the most likely modes of transmission. In response to this outbreak, the Government of Cambodia has taken measures to encourage safe injection practices by licensed medical professionals, ban unlicensed medical practitioners, increase local capacity for HIV testing and counseling, and expand access to HIV treatment in Battambang province. Measures to reduce the demand for unnecessary medical injections and the provision of unsafe injections are needed. Estimates of national HIV incidence and prevalence might need to be adjusted to account for unsafe injection as a risk exposure.

Safety engineered injection devices for intramuscular, subcutaneous and intradermal injections in healthcare delivery settings: a systematic review and meta-analysis

BACKGROUND

Occupational sharps injuries are associated with transmission of bloodborne viruses to healthcare workers, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Similarly reuse of syringes in healthcare settings might transmit these infections between patients. The objective of this study was to systematically review the evidence about the effects of the use by health care workers of two types of safety engineered injection devices, when delivering intramuscular, subcutaneous, or intradermal injectable medications: sharps injury protection syringes and reuse prevention syringes.

METHODS

We included both randomized and non-randomized studies comparing safety syringes to syringes without safety features. Outcomes of interest included needlestick injuries, and HIV, HBV and HCV infections amongst HCWs (for sharps injury prevention syringes) and patients (for reuse prevention syringes). When possible, we conducted meta-analyses using a random-effects model. We tested results for heterogeneity across studies using the I statistic. We assessed the quality of evidence by outcome using the GRADE methodology.

RESULTS

We included nine eligible studies: six assessed devices that qualify as sharps injury prevention devices, and three assessed devices that qualify as both injury prevention devices and reuse prevention devices. Eight studies were observational while one was randomized. All studies assessed a single outcome: needle stick injuries among healthcare workers. For sharp injury prevention syringes, the meta-analysis of five studies resulted in a pooled relative risk of 0.54 [0.41, 0.71] for the effect on needlestick injuries per healthcare worker. The associated quality of evidence was rated as moderate. For reuse prevention syringes, data from one study provided a relative risk of 0.40 [0.27, 0.59] for the effect on needlestick injuries per healthcare worker. The associated quality of evidence was rated as moderate. We identified no studies reporting on the effect on the reuse of syringes.

CONCLUSIONS

We identified moderate quality evidence that syringes with sharps injury prevention feature reduce the incidence of needlestick injuries per healthcare worker. We identified no studies reporting data for the remaining outcomes of interest for HCWs. Similarly we identified no studies reporting on the effect of syringes with a reuse prevention feature on the reuse of syringes or on the other outcomes of interest for patients.

Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby

An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Sexual motivation, sexual transactions and sexual risk behaviors in men who have sex with men in Dar es Salaam, Tanzania

Understanding the associations between sexual motivation and sexual risk behaviors of men who have sex with men (MSM) is critical for developing effective HIV prevention interventions. To examine these associations, we employed data from a survey of 200 MSM in Dar es Salaam, Tanzania, recruited through respondent driven sampling. Results showed that 44.5 % of surveyed participants most often looked for love/affection when having sex, and 36.5 % most often looked for money. Money-motivated MSM were more likely to identify themselves as bisexual, more likely to have anal sex, and had significantly higher numbers of partners of both sexes. Those who most often looked for love/affection were less likely to ask for condom use, to actually use a condom, and to use lubrication in anal sex. MSM with different sexual motivations had dissimilar sexual risk behaviors. Tailored health interventions for each group to reduce these sexual risks for STIs/HIV prevention are needed.

Potential for human immunodeficiency virus parenteral transmission in the Middle East and North Africa: An analysis using hepatitis C virus as a proxy biomarker

The Middle East and North Africa (MENA) region has endured several major events of infection parenteral transmission. Recent work has established the utility of using hepatitis C virus (HCV) as a proxy biomarker for assessing the epidemic potential for human immunodeficiency virus (HIV) parenteral transmission. In this review, we use data on the prevalence of HCV infection antibody (seroprevalence) among general population and high risk population groups to assess the potential for HIV parenteral transmission in MENA. Relatively low prevalence of HCV infection in the general population groups was reported in most MENA countries indicating that parenteral HIV transmission at endemic levels does not appear to be a cause for concern. Nonetheless, there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities. Though there have been steady improvements in safety measures related to parenteral modes of transmission in the region, these improvements have not been uniform across all countries. More precautions, including infection control training programs, surveillance systems for nosocomial infections and wider coverage and evaluation of hepatitis B virus immunization programs need to be implemented to avoid the unnecessary spread of HIV, HCV, and other blood-borne pathogens along the parenteral modes of transmission.

Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010

Background

In 2000, the World Health Organization estimated that, in developing and transitional countries, unsafe injections accounted for respectively 5%, 32% and 40% of new infections with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV). Safe injection campaigns were organized worldwide. The present study sought to measure the progress in reducing the transmission of these viruses through unsafe injections over the subsequent decade.

Methods

A mass action model was updated, to recalculate the number of injection-related HIV, HCV and HBV infections acquired in 2000 and provide estimates for 2010. Data about the annual number of unsafe injections were updated. HIV prevalence in various regions in 2000 and 2010 were calculated from UNAIDS data. The ratio of HIV prevalence in healthcare settings compared to the general population was estimated from a literature review. Improved regional estimates of the prevalence of HCV seropositivity, HBsAg and HBeAg antigenemia were used for 2000 and 2010. For HIV and HCV, revised estimates of the probability of transmission per episode of unsafe injection were used, with low and high values allowing sensitivity analyses.

Results

Despite a 13% population growth, there was a reduction of respectively 87% and 83% in the absolute numbers of HIV and HCV infections transmitted through injections. For HBV, the reduction was more marked (91%) due to the additional impact of vaccination. While injections-related cases had accounted for 4.6%–9.1% of newly acquired HIV infections in 2000, this proportion decreased to 0.7%–1.3% in 2010, when unsafe injections caused between 16,939 and 33,877 HIV infections, between 157,592 and 315,120 HCV infections, and 1,679,745 HBV infections.

Conclusion

From 2000 to 2010, substantial progress was made in reducing the burden of HIV, HCV and HBV infections transmitted through injections. In some regions, their elimination might become a reasonable public health goal.

Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny

We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for "sampling bias," (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.

Infection control and practice of standard precautions among healthcare workers in northern Nigeria

Background:

Healthcare-associated infections (HAIs) have been reported to be a serious problem in the healthcare services as they are common causes of illness and mortality among hospitalized patients including healthcare workers (HCWs). Compliance with these standard precautions has been shown to reduce the risk of exposure to blood and body fluids.

Aims:

This study therefore assesses the level of knowledge and compliance with standard precautions by the various cadre of HCWs and the factors influencing compliance in hospital environment in Nasarawa State, Northern Nigeria.

Settings and Design:

Nasarawa State has a current human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevalence rate of 10.0%, which was higher than most states in Nigeria with a high level of illiteracy and ignorance. Majority of the people reside in the rural areas while a few are found in the towns, informal settlements with no direct access to healthcare facilities are common.

Materials and Methods:

This study is an analytical, cross-sectional study. Proportional sampling technique was used to obtain a representative sample and a structured self-administered questionnaire was used to collect relevant information from the healthcare providers working in Nasarawa State from January to February 2009.

Statistical analysis used:

To describe patient characteristics, we calculated proportions and medians. For categorical variables, we compared proportions using chi-square tests. A logistic regression model was produced with infection control as outcome variable to identify associated factors.

Results:

A total of 421 HCWs were interviewed, Majority (77.9%) correctly describe universal precaution and infection control with 19.2, 19.2, and 28.0%, respectively unable to recognize vaccination, postexposure prophylaxis, and surveillance for emerging diseases as standard precaution for infection control. About 70.1% usually wear gloves before handling patients or patients’ care products, 12.6% reported wash their hand before wearing the gloves, 10.7% washed hands after removal of gloves, and 72.4% changed gloves after each patient. Only 3.3% had a sharp disposal system in their various workplaces. Majority (98.6%) of the respondents reported that the major reason for noncompliance to universal precautions is the nonavailability of the equipments. There was a statistically significant difference in the practice of standard precaution among those that were exposed to blood products and body fluid compared to those that had not been exposed in the last 6 months (χ² = 3.96, P = 0.03), public healthcare providers when compared to private health workers (χ² = 22.32, P = 0.001), among those working in secondary and tertiary facilities compared to primary healthcare centers (χ² = 14.64, P = 0.001) and urban areas when compared to rural areas (χ² = 4.06, P = 0.02). The only predictor of practice of standard precaution was exposure to blood and body fluid in the last 6 months odds ratio (OR) = 4.56 (confidence interval (CI) = 1.00-21.28).

Conclusions:

This study implies that inadequate workers’ knowledge and environment related problems, including the lack of protective materials and other equipments and utilities required to ensure safety of HCWs is a crucial issue that need urgent attention. Institution of a surveillance system for hospital acquired infection to improve consistent use of standard precautions among health workers is recommended in Nigeria and other low income countries in Africa.

'Behold, a virgin is with HIV!' misreporting sexual behavior among infected adolescents

In four Southern African countries where the HIV prevalence rate is among the highest in the world, 46.4% of a sample of female adolescents infected with HIV report having never engaged in sex. This would indicate either the dominance of non-sexual modes of HIV transmission or rampant misreporting of sexual behavior in the sample. We propose a method to estimate the extent of misreporting and calculate that the true percentages of virgins among the sample of HIV-infected adolescent women is 32.1%. After accounting for misreporting, the contribution of sexual modes of HIV transmission is projected as 50.4%, compared with an estimate of 35.5% if we assume no misreporting.

The distribution of sex acts and condom use within partnerships in a rural sub-Saharan African population

INTRODUCTION

In an HIV/AIDS epidemic driven primarily by heterosexual transmission, it is important to have an understanding of the human sexual behaviour patterns that influence transmission. We analysed the distribution and predictors of within-partnership sexual behaviour and condom use in rural Zimbabwe and generated parameters for use in future modelling analyses.

METHODS

A population-based cohort was recruited from a household census in 12 communities. A baseline survey was carried out in 1998-2000 with follow-up surveys after 3 and 5 years. Statistical distributions were fitted to reported within-partnership numbers of total, unprotected and protected sex acts in the past two weeks. Multilevel linear and logistic regression models were constructed to assess predictors of the frequency of unprotected sex and consistent condom use.

RESULTS

A normal distribution of ln(sex acts+1) provided the best fit for total and unprotected sex acts for men and women. A negative binomial distribution applied to the untransformed data provided the best fit for protected sex acts. Condom use within partnerships was predominantly bimodal with at least 88% reporting zero or 100% use. Both men and women reported fewer unprotected sex acts with non-regular compared to regular partners (men: 0.26 fewer every two weeks (95% confidence interval 0.18-0.34); women: 0.16 (0.07-0.23)). Never and previously married individuals reported fewer unprotected sex acts than currently married individuals (never married men: 0.64 (0.60-0.67); previously married men: 0.59 (0.50-0.67); never married women: 0.51 (0.45-0.57); previously married women: 0.42 (0.37-0.47)). These variables were also associated with more consistent condom use.

DISCUSSION

We generated parameters that will be useful for defining transmission models of HIV and other STIs, which rely on a valid representation of the underlying sexual network that determines spread of an infection. This will enable a better understanding of the spread of HIV and other STDs in this rural sub-Saharan population.

Enhanced heterosexual transmission hypothesis for the origin of pandemic HIV-1

HIV-1 M originated from SIVcpz endemic in chimpanzees from southeast Cameroon or neighboring areas, and it started to spread in the early 20th century. Here we examine the factors that may have contributed to simian-to-human transmission, local transmission between humans, and export to a city. The region had intense ape hunting, social disruption, commercial sex work, STDs, and traffic to/from Kinshasa in the period 1899-1923. Injection treatments increased sharply around 1930; however, their frequency among local patients was far lower than among modern groups experiencing parenteral HIV-1 outbreaks. Recent molecular datings of HIV-1 M fit better the period of maximal resource exploitation and trade links than the period of high injection intensity. We conclude that although local parenteral outbreaks might have occurred, these are unlikely to have caused massive transmission. World War I led to additional, and hitherto unrecognized, risks of HIV-1 emergence. We propose an Enhanced Heterosexual Transmission Hypothesis for the origin of HIV-1 M, featuring at the time and place of its origin a coincidence of favorable co-factors (ape hunting, social disruption, STDs, and mobility) for both cross-species transmission and heterosexual spread. Our hypothesis does not exclude a role for parenteral transmission in the initial viral adaptation.

Estimating the Burden of Disease from Unsafe Injections in India: A Cost-benefit Assessment of the Auto-disable Syringe in a Country with Low Blood-borne Virus Prevalence

Background:

Unsafe medical injections are a prevalent risk factor for viral hepatitis and HIV in India.

Objectives:

This review undertakes a cost–benefit assessment of the auto-disable syringe, now being introduced to prevent the spread of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV).

Materials and Methods:

The World Health Organization methods for modeling the global burden of disease from unsafe medical injections are reproduced, correcting for the concentrated structure of the HIV epidemic in India. A systematic review of risk factor analyses in India that investigate injection risks is used in the uncertainty analysis.

Results:

The median population attributable fraction for hepatitis B carriage associated with recent injections is 46%, the median fraction of hepatitis C infections attributed to unsafe medical injections is 38%, and the median fraction of incident HIV infections attributed to medical injections is 12% in India. The modeled incidence of blood-borne viruses suggests that introducing the auto-disable syringe will impose an incremental cost of $46–48 per disability adjusted life year (DALY) averted. The epidemiological evidence suggests that the incremental cost of introducing the auto-disable syringe for all medical injections is between $39 and $79 per DALY averted.

Conclusions:

The auto-disable syringe is a cost-effective alternative to the reuse of syringes in a country with low prevalence of blood-borne viruses.

The evolving epidemiology of HIV/AIDS

Following its recognition in 1981, the HIV/AIDS epidemic has evolved to become the greatest challenge in global health, with some 34 million persons living with HIV worldwide. Early epidemiologic studies identified the major transmission routes of the virus before it was discovered, and enabled the implementation of prevention strategies. Although the first identified cases were in MSM in the United States and western Europe, the greatest impact of the epidemic has been in sub-Saharan Africa, where most of the transmission occurs between heterosexuals. Nine countries in southern Africa account for less than 2% of the world's population but now they represent about one third of global HIV infections. Where broadly implemented, HIV screening of donated blood and antiretroviral treatment (ART) of pregnant women have been highly effective in preventing transfusion-associated and perinatally acquired HIV, respectively. Access to sterile equipment has also been a successful intervention for injection drug users. Prevention of sexual transmission has been more difficult. Perhaps the greatest challenge in terms of prevention has been in the global community of MSM in which HIV remains endemic at high prevalence. The most promising interventions are male circumcision for prevention of female-to-male transmission and use of ART to reduce infectiousness, but the extent to which these interventions can be brought to scale will determine their population-level impact.

Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa

Heterosexual exposure accounts for most HIV transmission in sub-Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost-wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non-sex-related drivers play a major role in HIV transmission in sub-Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.

Concurrency revisited: increasing and compelling epidemiological evidence

Multiple sexual partnerships must necessarily lie at the root of a sexually transmitted epidemic. However, that overlapping or concurrent partnerships have played a pivotal role in the generalized epidemics of sub-Saharan Africa has been challenged. Much of the original proposition that concurrent partnerships play such a role focused on modelling, self-reported sexual behaviour data and ethnographic data. While each of these has definite merit, each also has had methodological limitations. Actually, more recent cross-national sexual behaviour data and improved modelling have strengthened these lines of evidence. However, heretofore the epidemiologic evidence has not been systematically brought to bear. Though assessing the epidemiologic evidence regarding concurrency has its challenges, a careful examination, especially of those studies that have assessed HIV incidence, clearly indicates a key role for concurrency.Such evidence includes: 1) the early and dramatic rise of HIV infection in generalized epidemics that can only arise from transmission through rapid sequential acute infections and thereby concurrency; 2) clear evidence from incidence studies that a major portion of transmission in the population occurs via concurrency both for concordant negative and discordant couples; 3) elevation in risk associated with partner's multiple partnering; 4) declines in HIV associated with declines in concurrency; 5) bursts and clustering of incident infections that indicate concurrency and acute infection play a key role in the propagation of epidemics; and 6) a lack of other plausible explanations, including serial monogamy and non-sexual transmission. While other factors, such as sexually transmitted infections, other infectious diseases, biological factors and HIV sub-type, likely play a role in enhancing transmission, it appears most plausible that these would amplify the role of concurrency rather than alter it. Additionally, critics of concurrency have not proposed plausible alternative explanations for why the explosive generalized epidemics occurred. Specific behaviour change messaging bringing the concepts of multiple partnering and concurrency together appears salient and valid in promoting safer individual behaviour and positive social norms.

Concurrent partnerships and HIV: an inconvenient truth

The strength of the evidence linking concurrency to HIV epidemic severity in southern and eastern Africa led the Joint United Nations Programme on HIV/AIDS and the Southern African Development Community in 2006 to conclude that high rates of concurrent sexual partnerships, combined with low rates of male circumcision and infrequent condom use, are major drivers of the AIDS epidemic in southern Africa. In a recent article in the Journal of the International AIDS Society, Larry Sawers and Eileen Stillwaggon attempt to challenge the evidence for the importance of concurrency and call for an end to research on the topic. However, their "systematic review of the evidence" is not an accurate summary of the research on concurrent partnerships and HIV, and it contains factual errors concerning the measurement and mathematical modelling of concurrency.Practical prevention-oriented research on concurrency is only just beginning. Most interventions to raise awareness about the risks of concurrency are less than two years old; few evaluations and no randomized-controlled trials of these programmes have been conducted. Determining whether these interventions can help people better assess their own risks and take steps to reduce them remains an important task for research. This kind of research is indeed the only way to obtain conclusive evidence on the role of concurrency, the programmes needed for effective prevention, the willingness of people to change behaviour, and the obstacles to change.

Peer group intervention reduces personal HIV risk for Malawian health workers

PURPOSE

To test a peer group intervention to address personal HIV prevention needs of rural health workers in Malawi.

DESIGN

Using a quasi-experimental design, we compared district health workers in two districts of Malawi that were randomly assigned to either the intervention or delayed control condition. We used independent sample surveys at baseline, 15 months, and 30 months postintervention. Intervention district workers received a peer group intervention after the baseline; control district workers received the delayed intervention after final data collection.

METHODS

The 10-session intervention for primary prevention of HIV infection was based on the primary healthcare model, behavioral change theory, and contextual tailoring based on formative evaluation. Differences in HIV-related knowledge, attitudes, self-efficacy, and behaviors were analyzed using t tests and multiple regression controlling for baseline differences.

FINDINGS

Health workers in the intervention district had higher general HIV knowledge, more positive attitudes about condoms, higher self-efficacy for safer sex, and more involvement in community HIV prevention at both the 15-month and 30-month postintervention survey. At 30 months, intervention district workers also reported less stigmatizing attitudes toward persons living with AIDS, more HIV tests, and lower risky sexual behaviors.

CONCLUSION

The intervention should be sustained in current sites and scaled up for health workers throughout Malawi as part of a multisectoral response to HIV prevention.

CLINICAL RELEVANCE

Incorporating a peer group intervention focused on personal as well as work-related HIV prevention can reduce health workers' risky behaviors in their personal lives, potentially reducing morbidity and mortality and enhancing workforce retention. Reducing stigmatizing attitudes may also improve the quality of health services.

Uncovering high rates of unsafe injection equipment reuse in rural Cameroon: validation of a survey instrument that probes for specific misconceptions

BACKGROUND

Unsafe reuse of injection equipment in hospitals is an on-going threat to patient safety in many parts of Africa. The extent of this problem is difficult to measure. Standard WHO injection safety assessment protocols used in the 2003 national injection safety assessment in Cameroon are problematic because health workers often behave differently under the observation of visitors. The main objective of this study is to assess the extent of unsafe injection equipment reuse and potential for blood-borne virus transmission in Cameroon. This can be done by probing for misconceptions about injection safety that explain reuse without sterilization. These misconceptions concern useless precautions against cross-contamination, i.e. "indirect reuse" of injection equipment. To investigate whether a shortage of supply explains unsafe reuse, we compared our survey data against records of purchases.

METHODS

All health workers at public hospitals in two health districts in the Northwest Province of Cameroon were interviewed about their own injection practices. Injection equipment supply purchase records documented for January to December 2009 were compared with self-reported rates of syringe reuse. The number of HIV, HBV and HCV infections that result from unsafe medical injections in these health districts is estimated from the frequency of unsafe reuse, the number of injections performed, the probability that reused injection equipment had just been used on an infected patient, the size of the susceptible population, and the transmission efficiency of each virus in an injection.

RESULTS

Injection equipment reuse occurs commonly in the Northwest Province of Cameroon, practiced by 44% of health workers at public hospitals. Self-reported rates of syringe reuse only partly explained by records on injection equipment supplied to these hospitals, showing a shortage of syringes where syringes are reused. Injection safety interventions could prevent an estimated 14-336 HIV infections, 248-661 HBV infections and 7-114 HCV infections each year in these health districts.

CONCLUSIONS

Injection safety assessments that probe for indirect reuse may be more effective than observational assessments. The autodisable syringe may be an appropriate solution to injection safety problems in some hospitals in Cameroon. Advocacy for injection safety interventions should be a public health priority.

Selected biochemical and hematological abnormalities in Nigerians with human immunodeficiency virus and hepatitis C virus coinfection

Background

Liver disease has emerged as a major cause of morbidity and mortality in patients with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection, now that antiretroviral therapy has become more effective and has prolonged life expectancy in HIV-infected patients. The main objectives of this study were to determine the prevalence of HIV/HCV coinfection and the pattern of hematological and biochemical abnormalities associated with such dual infection.

Methods

In this study, patients with HIV infection (cases) were tested for anti-HCV antibodies. There was a control group made up of apparently healthy individuals who came to hospital for medical examination for various reasons. They also had an anti-HCV antibody test. Those who tested positive for anti-HCV antibodies among the cases and control subjects were further evaluated for hemoglobin concentration, total white cell count, platelet count, and liver function.

Results

One hundred and eighty HIV-infected patients and 180 control subjects participated in the study. The seroprevalence of anti-HCV antibodies in the HIV-infected patients and control subjects were 6.7% and 4.4%, respectively (P = 0.57). Serum total bilirubin, conjugated bilirubin, and alkaline phosphatase were significantly higher in the HIV/HCV coinfected patients compared with their HCV monoinfected counterparts (P = 0.0396, 0.0001, and 0.0016, respectively). The mean hemoglobin, white cell count, platelet count, and CD4+ T lymphocyte count were significantly lower in the HIV/HCV coinfected patients than the HCV monoinfected control group (P = 0.0082, 0.0133, 0.0031, and 0.0001, respectively).

Conclusion

The seroprevalence of anti-HCV antibodies in HIV-infected Nigerian patients is 6.7%. Patients with HIV/HCV coinfection have lower blood counts, higher serum bilirubin, and higher serum alkaline phosphatase compared with patients having HCV monoinfection.

HIV status in discordant couples in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Most couples affected by HIV/AIDS in sub-Saharan Africa live in discordant relationships. Men are thought to be the index case in most relationships, and most social marketing and awareness campaigns are focused on men. We investigated serodiscordance in stable relationships to establish the gender balance of index-case infections.

METHODS

We did a systematic review, random-effects meta-analysis, and meta-regression of published and unpublished studies enrolling discordant couples and assessed the proportion of men and women that were index cases. We repeated the analysis with data from demographic and health surveys (DHS) from the 14 countries that have documented the HIV status of couples. Our primary outcome was the total number of HIV discordant couples, including the proportion of HIV-positive women.

FINDINGS

We included data from 27 cohorts of 13,061 couples and DHS data from 14 countries of 1145 couples. The proportion of HIV-positive women in stable heterosexual serodiscordant relationships was 47% (95% CI 43-52), which shows that women are as likely as men to be the index partner in a discordant couple. DHS data (46%, 41-51) and our sensitivity analysis (47%, 43-52) showed similar findings. Meta-regression showed that urban versus rural residence (odds ratio 0.31, 95% CI 0.22-0.39), latitude (β coefficient 0.02, 0.023-0.034), gender equality (β coefficient -0.42, -0.56 to -0.27), HIV prevalence (β coefficient -0.037, -0.04 to -0.030), and older age (β coefficient 0.20, 0.08-0.32) were associated with the proportion of female index cases.

INTERPRETATION

Our study shows the need to focus on both sexes in HIV prevention strategies, such as promotion of condom use and mitigation of risk behaviours.

FUNDING

None.

What is the use? An international look at reuse of single-use medical devices

Reuse of single-use devices is common in most countries worldwide. We provide an overview of the issue from an international perspective. In many developing and transitional countries reuse of cheap single-use devices (needles, syringes, surgical gloves) is common leading to large numbers of unsafe interventions, specifically injections and, as a consequence, infection with hepatitis B, C or HIV. There are various reasons for reuse: limited resources, insufficient knowledge of healthcare workers and the belief of patients that injection is more beneficial than oral medication. Reuse of cheap single-use devices should cease and both medical staff and the public should be informed about potential safety risks associated with injection. In developed countries, reuse of single-use items is less common but may include expensive technical products. Reuse is regulated in many countries (e.g. US, Canada, some European countries) demanding ethical and legal considerations, high standards of reprocessing and training of staff, risk assessment, management and validation of reprocessing. Well regulated reprocessing can decrease the number of single-use devices reprocessed. In developing as well as developed countries, a decision to reprocess single-use devices should only be made after a critical reflection of advantages and disadvantages.

AIDS epidemiology in Africa: a changing of the guard

With recent implementation of studies specifically designed to empirically assess the contribution of both sexual and blood-borne exposures to local HIV transmission in sub-Saharan Africa, and with the arrival of a new generation of investigators, a picture of HIV transmission routes of improved validity is emerging. Seven years ago the International Journal of STD & AIDS (IJSA) began actively encouraging reexamination of the prevailing view that penile-vaginal sex was driving African HIV epidemics, welcoming debate via manuscript submission and presentation of fresh scientific evidence. Although the IJSA-published dissenting views have largely been ignored, dismissed or fiercely resisted by established HIV researchers and allied health agencies, new approaches may yet elicit more rational, evidence-based responses. Several such contributions appear in IJSA's present theme issue on aspects of HIV epidemiology in Africa. The focus on recent empiric data, rather than on modelling or speculation, no longer leaves reasonable doubt that sexual behaviours are insufficient to explain 'Why Africa?' It is fitting that this progress was encouraged, from beginning to end, by long-time, and now departing IJSA Editor-in-Chief, Dr Wallace Dinsmore.

Double standards in research ethics, health-care safety, and scientific rigour allowed Africa's HIV/AIDS epidemic disasters

Medical professionals practising double standards in research ethics, health-care safety and scientific rigour have allowed HIV epidemics to develop into national disasters in more than a dozen countries in sub-Saharan Africa. Researchers have followed HIV-positive Africans who did not know they were infected to study HIV-related morbidity, mortality and transmission to unsuspecting spouses and children. Public health managers do not warn Africans about risks to contract HIV from unsafe health care, and no African government has investigated any unexplained and suspected nosocomial HIV infection by tracing and testing people who attended suspected clinics. Researchers have avoided finding and talking about nosocomial HIV infections in countries with generalized epidemics. Rejecting double standards in health-care safety and scientific rigour may be essential to solve and stop Africa's HIV epidemic. Allowing competitive international trade in generic drugs to treat AIDS could mitigate some of the harm done by these double standards.

Injection risks and HIV transmission in the Republic of South Africa

The sexualization of the HIV epidemic in South Africa has been used as evidence that unsafe medical injections are of minimal importance to transmission in Africa, because the country was thought to be free of unsafe injection risks. More recent observation reveals routine failures in infection control in South African maternity and paediatric wards and in public dental clinics. In one province at least one medical injection in five is administered with a used needle or syringe. Over 25% of new HIV infections identified in South African adults using the BED IgG capture enzyme immunoassay in 2005 were in individuals reporting they had not been sexually active in the past 12 months. Immunization injections received at public health facilities are associated with HIV infections in children, many of whom may have passed HIV to their mothers during breastfeeding. South Africa is one of few countries in sub-Saharan Africa not using auto-disable (non-reusable) syringes for all immunizations. Using resource scarcity as justification for needle reuse is ethically indefensible, as injection safety is a readily achievable goal.

Non-vertical HIV transmission to children in sub-Saharan Africa

This review considers whether HIV prevalence data on children in sub-Saharan Africa support the hypothesis that blood exposures account for a large proportion of HIV infections in Africa. Data from a systematic search on HIV-infected children support two analyses. In 25 studies where the mothers' HIV status was not matched with data on each child (excluding non-representative samples of children), the observed prevalence in children in 20 studies was greater than expected from vertical transmission. The population-weighted difference – 1.3% – was approximately one-third of observed prevalence in children. In 32 studies that match HIV-positive children with HIV-negative mothers, 406 discordant mother–child pairs were identified, and in studies identifying at least five non-vertical infections in children, 17.5% of HIV-positive children had HIV-negative mothers. In discussing an important role for unsafe health care in exceptionally rapid HIV transmission in Africa, leading AIDS researchers cite low HIV prevalence in children not yet sexually active. The assumption that childhood HIV prevalence would increase with age in children, if injections transmitted HIV is shown to be erroneous; it fails to account for early mortality in HIV-positive children. Evidence of child-to-child HIV transmission supports the theory that nosocomial infections are important to the AIDS pandemic, and procedures more prevalent than blood transfusions, such as injections, are likely involved.

Risk behaviors in volunteer blood donors who seroconverted for HIV, Abidjan, Côte d'Ivoire 1997 to 2005

BACKGROUND

The residual risk of human immunodeficiency virus (HIV) transmission from blood products in the Abidjan National Blood Transfusion Center was estimated to be 1 in 5780 blood donations over the period 2002 through 2004. We aimed at describing risk behaviors in blood donors who seroconverted for HIV in Abidjan to improve the pre-blood donation selection.

STUDY DESIGN AND METHODS

We investigated the behavioral profile of HIV seroconverters assessed before their HIV diagnosis, during the blood donation selection at the blood bank of Abidjan, and compared it to the profile documented after this HIV diagnosis, at enrollment in the PRIMO-CI cohort. Since 1997, enrollment in this cohort is offered to every blood donor whose delay since HIV seroconversion was 36 months or less.

RESULTS

Among the 418 blood donors who seroconverted for HIV between 1997 and 2005, 241 were enrolled in the cohort. Median age was 28 years and 63% were men. The median time between the last HIV-negative test and the first positive test was 7 months. Since the last blood donation, 29% of donors reported unprotected sexual intercourse with multiple casual sexual partners, 55% unprotected sexual intercourse with one casual sexual partner, and 36% sharing of nail clippers. During the pre-blood donation questionnaire, 69% of HIV seroconverters had reported unprotected sexual intercourse since the last blood donation (vs. 89% reported after donation), and 7% had had multiple casual sexual partners (vs. 32%).

CONCLUSION

Volunteer blood donors who seroconverted for HIV in Abidjan reported a high proportion of unprotected sexual intercourse with casual sexual partners.

The Malawi Religion Project: Data collection and selected analyses

Scholars have recently become increasingly interested in the role religion plays in the responses to the HIV/AIDS epidemic in sub-Saharan Africa. Here, we present the Malawi Religion Project (MRP), which provides data to examine the relationship between religion and HIV/AIDS through surveys and in-depth interviews with denominational leaders, congregational leaders, and congregation members in three districts of rural Malawi. In the paper, we outline existing perspectives on the religion-HIV/AIDS link, describe the MRP's design, implementation, and subsequent data; provide initial evidence for a series of general research hypotheses; and describe how these data can be used both to extend explorations of these relationships further and as a model for gathering similar data in other contexts. In particular we highlight the unique possibilities this project provides for analyses that link MRP data to the Malawi Diffusion and Ideational Change Project. These linked data produce a multi-level data set covering individuals, congregations and their communities, allowing empirical research on religion, HIV/AIDS risk, related behaviors, attitudes, and norms.

Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review

The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.However injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region. IDU is increasingly common among young adults in sub-Saharan Africa and is associated with high risk sex, thus linking IDU to the already well established and concentrated generalized HIV epidemics in the region. Demand reduction programs based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services.Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm reduction programs e.g. needle exchange programs are almost non-existent in the region. Among injection drug users and among drug treatment patients in Africa, knowledge that needle sharing and syringe reuse transmit HIV is still very limited, in contrast with the more successfully instilled knowledge that HIV is transmitted sexually. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia, and North America.

HIV prevalence and associated risk factors among individuals aged 13-34 years in Rural Western Kenya

OBJECTIVES

To estimate HIV prevalence and characterize risk factors among young adults in Asembo, rural western Kenya.

DESIGN

Community-based cross-sectional survey.

METHODS

From a demographic surveillance system, we selected a random sample of residents aged 13-34 years, who were contacted at home and invited to a nearby mobile study site. Consent procedures for non-emancipated minors required assent and parental consent. From October 2003 - April 2004, consenting participants were interviewed on risk behavior and tested for HIV and HSV-2. HIV voluntary counseling and testing was offered.

RESULTS

Of 2606 eligible residents, 1822 (70%) enrolled. Primary reasons for refusal included not wanting blood taken, not wanting to learn HIV status, and partner/parental objection. Females comprised 53% of 1762 participants providing blood. Adjusted HIV prevalence was 15.4% overall: 20.5% among females and 10.2% among males. HIV prevalence was highest in women aged 25-29 years (36.5%) and men aged 30-34 years (41.1%). HSV-2 prevalence was 40.0% overall: 53% among females, 25.8% among males. In multivariate models stratified by gender and marital status, HIV infection was strongly associated with age, higher number of sex partners, widowhood, and HSV-2 seropositivity.

CONCLUSIONS

Asembo has extremely high HIV and HSV-2 prevalence, and probable high incidence, among young adults. Further research on circumstances around HIV acquisition in young women and novel prevention strategies (vaccines, microbicides, pre-exposure prophylaxis, HSV-2 prevention, etc.) are urgently needed.

Increase in clinical prevalence of AIDS implies increase in unsafe medical injections

A mass action model developed by the World Health Organization (WHO) estimates that the re-use of contaminated syringes for medical care accounted for 2.5% of HIV infections in sub-Saharan Africa in 2000. The WHO's model applies the population prevalence of HIV infection rather than the clinical prevalence to calculate patients' frequency of exposure to contaminated injections. This approach underestimates iatrogenic exposure risks when progression to advanced HIV disease is widespread. This sensitivity analysis applies the clinical prevalence of HIV to the model and re-evaluates the transmission efficiency of HIV in injections. These adjustments show that no less than 12-17%, and up to 34-47%, of new HIV infections in sub-Saharan Africa may be attributed to medical injections. The present estimates undermine persistent claims that injection safety improvements would have only a minor impact on HIV incidence in Africa.

Impact of a peer-group intervention on occupation-related behaviors for urban hospital workers in Malawi

Using a pre- and posttest design with no control group, the authors evaluated the impact of a peer-group intervention on work related knowledge and behavior for health workers at an urban hospital in Malawi. The authors surveyed unmatched random samples of health workers, observed workers on the job, and interviewed clients about hospital services at baseline and at 6 months after the intervention. Universal precautions knowledge, reported hand washing, and reported client teaching were significantly higher at the final evaluation. The outcome differences remained robust in multivariate analyses with controls for demographic factors of age, gender, education, food security, and job category. Observations reported consistently greater use of universal precautions, more respectful interactions, and more client teaching at final evaluation. Patient surveys reported more discussion with health workers about HIV at the final evaluation. Peer-group interventions can prepare health workers in Malawi for HIV prevention and offer a potential model for other African countries.

Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies

We did a systematic review and meta-analysis of observational studies of the risk of HIV-1 transmission per heterosexual contact. 43 publications comprising 25 different study populations were identified. Pooled female-to-male (0.04% per act [95% CI 0.01-0.14]) and male-to-female (0.08% per act [95% CI 0.06-0.11]) transmission estimates in high-income countries indicated a low risk of infection in the absence of antiretrovirals. Low-income country female-to-male (0.38% per act [95% CI 0.13-1.10]) and male-to-female (0.30% per act [95% CI 0.14-0.63]) estimates in the absence of commercial sex exposure (CSE) were higher. In meta-regression analysis, the infectivity across estimates in the absence of CSE was significantly associated with sex, setting, the interaction between setting and sex, and antenatal HIV prevalence. The pooled receptive anal intercourse estimate was much higher (1.7% per act [95% CI 0.3-8.9]). Estimates for the early and late phases of HIV infection were 9.2 (95% CI 4.5-18.8) and 7.3 (95% CI 4.5-11.9) times larger, respectively, than for the asymptomatic phase. After adjusting for CSE, presence or history of genital ulcers in either couple member increased per-act infectivity 5.3 (95% CI 1.4-19.5) times versus no sexually transmitted infection. Study estimates among non-circumcised men were at least twice those among circumcised men. Low-income country estimates were more heterogeneous than high-income country estimates, which indicates poorer study quality, greater heterogeneity of risk factors, or under-reporting of high-risk behaviour. Efforts are needed to better understand these differences and to quantify infectivity in low-income countries.

Denialism undermines AIDS prevention in sub-Saharan Africa

Some denialists, widely reviled, contend that HIV does not cause AIDS. Other denialists, widely respected, contend that HIV transmits so poorly through trace blood exposures that iatrogenic infections are rare. This second group of denialists has had a corrosive effect on public health and HIV programmes in sub-Saharan Africa. Guided by this second group of denialists, no African government has investigated unexplained HIV infections. Denialists have withheld and ignored research findings showing that non-sexual risks account for substantial proportions of HIV infections in Africa. Denialists have promoted invasive procedures for HIV prevention in Africa--injections for sexually transmitted infections, and adult male circumcision--without addressing unreliable sterilization of reused instruments. By denying that health care causes more than rare infections, denialists blame (stigmatize) HIV-positive African adults for causing their own infections through sexual behaviour. Denialism must be overcome to ensure safe health care and to combat HIV-related stigma in Africa.

Cost-effectiveness of HIV screening of blood donations in Accra (Ghana)

OBJECTIVES

Areas with high HIV-incidence rates compared to the developed world may benefit from additional testing in blood banks and may show more favorable cost-effectiveness ratios. We evaluated the cost-effectiveness of adding p24 antigen, mini pool nucleic acid amplification testing (MP-NAT), or individual donation NAT (ID-NAT) to the HIV-antibody screening at the Korle Bu Teaching Hospital (Accra, Ghana), where currently only HIV-antibody screening is undertaken.

METHODS

The residual risk of HIV transmission was derived from blood donations to the blood bank of the Korle Bu Teaching Hospital in 2004. Remaining life expectancies of patients receiving blood transfusion were estimated using the World Health Organization life expectancies. Cost-effectiveness ratios for adding the tests to HIV-antibody screening only were determined using a decision tree model and a Markov model for HIV.

RESULTS

The prevalence of HIV was estimated at 1.51% in 18,714 donations during 2004. The incremental cost per disability-adjusted life-year (DALY) averted was US$1237 for p24 antigen, US$3142 for MP-NAT and US$7695 compared to the next least expensive strategy. HIV-antibody screening itself was cost-saving compared to no screening at all, gaining US$73.85 and averting 0.86 DALY per transfused patient. Up to a willingness-to-pay of US$2736 per DALY averted, HIV-antibody screening without additional testing was the most cost-effective strategy. Over a willingness-to-pay of US$11,828 per DALY averted, ID-NAT was significantly more cost-effective than the other strategies.

CONCLUSIONS

Adding p24 antigen, MP-NAT, or ID-NAT to the current antibody screening cannot be regarded as a cost-effective health-care intervention for Ghana.

Antenatal clinic HIV data found to underestimate actual prevalence declines: evidence from Zambia

OBJECTIVE

To determine to what extent antenatal clinic (ANC)-based estimates reflect HIV prevalence trends among men and women in a high prevalence urban population.

METHODS

Examination of data from serial population-based HIV surveys in 1995 (n = 2115), 1999 (n = 1962) and 2003 (n = 2692), and ANC-based surveillance in 1994 (n = 450), 1998 (n = 810) and 2002 (n = 786) in the same site in Lusaka, Zambia. The population-based surveys recorded refusal rates between 6% and 10% during the three rounds.

RESULTS

Among ANC attendees, prevalence declined by 20% (25.0% to 19.9%; P = 0.101) in the age group 15-24 years and was stable overall. In the general population, the prevalence declined by 49% (P < 0.001) and by 32% (P < 0.001) in age group 15-24 and 15-49, respectively. Among women only, HIV prevalence declined by 44% (22.5% to 12.5%; P < 0.001) and by 27% (29.6% to 21.7%; P < 0.001) in age group 15-24 and 15-49 years, respectively. In addition, prevalence substantially declined in higher educated women aged 15-24 years (20.7% to 8.5%, P < 0.001).

CONCLUSION

ANC-based estimates substantially underestimated declines in HIV prevalence in the general population. This seemed to be partially explained by a combination of marked differentials in prevalence change by educational attainment and changes in fertility-related behaviours among young women. These results have important implications for the interpretation of ANC-based HIV estimates and underscore the importance of population-based surveys.