Earlier this week, I attended a symposium entitled “HIV Scale-Up and Global Health Systems” hosted by Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP). During the panel moderated by Stephen Lewis, which included former US President Bill Clinton, the moderator stopped the discussion to make the point that his organization does not use the term “mother-to-child” transmission of HIV because that places to much blame on the woman. Instead, they use the term “vertical transmission” – between generations. I found his emphasis humorous, not because I don’t agree with the idea of not blaming women, but because he was making such a big deal out of what I assumed was essentially the only way children acquired HIV.

Yesterday, Kim Yi Dionne on her blog haba na haba made me aware of a debate that apparently has been brewing under the radar in the HIV community for some time, one that seems to have a small number of ardent supporters, but one that is not readily accepted by the mainstream research community.
It turns out that there are many out there who believe that non-sexual transmission may account for a substantial fraction of HIV infections in some Sub-Saharan African countries, including among children.

A Telegraph article suggests that up to 1/5. Given that we generally assume young children to be sexually inactive, the authors speculate that blood exposure, through needles or through other forms of contamination is to blame. A whole edition of the journal “International Journal of STDs and AIDS” was recently devoted to a review of the research on this topic.

The primary form of evidence that exists to support this view is that a number of sero-prevalence studies have found rates of HIV infection among children to be too high to be explained by vertical transmission alone (I am not quite sure what is a normal rate) as well documented cases of HIV infected children born to HIV negative mothers. There are also qualitative surveys that have asked about all exposure risks and have relatively high rates of reported blood exposures in different populations and that people living in Africa may have much greater exposure to injections and vaccinations than in other parts of the world – partially due to injections for malaria. Together, these studies have been taken together to argue that blood exposure may account for a substantial fraction of transmission in Africa and that it has not received enough attention as it deserves from the prevention community.

I read through some of the research papers and thought some of them made strong inferences from rather limited data (e.g. the 1/5 figure came from a study of children in Swaziland, of which there were only 50 in the sample, and only 11 of which reported to be sero-discordant from their parents. Other issues, such as remarriage, false positives and false negatives, small sample size, and other potential explanations were not given enough discussion) but just the same I found the idea perplexing and interesting. PEPFAR has focused a lot of attention on blood safety in many developing countries, but perhaps more emphasis also needs to be placed on other injections and needle use as well.

Anyone out there know more about this issue that they would be up for sharing?

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3 Responses to “Non-sexual transmission of HIV in Sub-Saharan Africa”

  1. Anonymous says:

    President Clinton still has problems with truth. Right there on the Clinton HIV/AIDS Intiative website is: "Preventing the transmission of the disease from mothers to their children."

  2. Wellescent Health Blog says:

    It couldn't hurt to focus more attention on data collection related to the the various modes of disease transmission in Africa. Whether it be HIV or other diseases in the population, this information would likely well serve those providing health services to the population to improve effectiveness with limited resources.

  3. Brian Hanley says:

    I think there is a blind spot in HIV transmission research relative to sexual transmission to children. I cannot say with certainty, but I have had correspondence with Africans on the general topic of disparity between reports and actual behavior.

    I have also thought for many years about the implications of what a prominent AIDS physician told a patient of his 17 years ago about AIDS and school age kids. At that time this one physician was treating 15 kids at one school. (A very well known and wealthy public school.) With HIV taking 5-7 years to develop illness, and no signs of drug use or use of needles, doing the math on these kids leads to a simple conclusion. They were used by HIV+ adult men while under the age of 10.

    Since other studies have shown MSM's who are promiscuous on average seroconvert after roughly 200 contacts, it is likely these kids were sexually abused quite a bit.

    But, because of our current regulations we can't track it and study it. I have talked to one politician and deputy AG about trying to tackle it. But they are not willing to cross the HIV-rights lobby.

    Given that this occurs in major US cities, the proposition that there is not quite a bit of it in Africa is hard for me to believe.

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