How to contain generalized HIV epidemics? A plea for better evidence to displace speculation.

In the worst generalized HIV epidemics in East and Southern Africa, from one-quarter to three-quarters of women aged 15 years can expect to be living with HIV or to have died with AIDS by age 40 years. This disaster continues in the face of massive HIV prevention programmes based on current inexact knowledge of HIV transmission pathways and risks. To stop this disaster, both the public and public health experts need better information about the specific factors that allow HIV to propagate so extensively in countries with generalized epidemics. This knowledge could be acquired by tracing HIV infections to their source - especially tracing HIV infections in women of all ages, and tracing unexplained HIV infections in children with HIV-negative mothers.

Knowledge of HIV survival on skin-piercing instruments among young adults in Nyanza Province, Kenya.

In countries with generalized HIV epidemics, people may be exposed to blood-borne HIV at their home as well as during health care and cosmetic services. We asked young adults from the Luo and Kisii ethnic groups in Nyanza Province, Kenya, how long HIV survives in blood and how to clean skin-piercing instruments. Only 21% thought that HIV could survive more than an hour in dry conditions (although it can survive for days), and only 24% thought it could survive more than a week in wet conditions (although it can survive more than four weeks). The Kisii, with lower HIV prevalence, were more knowledgeable than the Luo about HIV survival. Survey participants reported that barbers and other service providers often cleaned instruments by wiping with alcohol or bleach, a practice which does not reliably inactivate HIV. People we interviewed, at risk from blood-borne HIV, did not know enough to protect themselves.

Exploratory study of blood exposures that are risks for HIV among Luo and Kisii ethnic groups in Nyanza province, Kenya.

Adult HIV prevalence exceeds 5% among all Kenyans, and 20% among the Luo ethnic group. Recent studies have associated HIV infections in Kenya with several invasive health care and cosmetic procedures. To explore the various blood exposures that could contribute to HIV infections in Kenya, we surveyed 320 adolescents and adults aged 15-29 years from the Luo and Kisii ethnic groups. Survey participants reported a wide range of invasive procedures in health care (including circumcisions, dental care, blood tests, and 1-60 injections or infusions for specific health problems), in cosmetic services (including tattooing and piercing) and around the home (through shaving body hair, fights, sports and other activities). Luo were significantly more likely than Kisii to report some risks (e.g. tattooing by a traditional expert, piercing), but less likely to report others (e.g. blood tests for malaria, anaesthetic injections during circumcision).