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.
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