HIV infections as unanticipated problems during medical research in Africa.

Regulations and guidelines in the United States, Canada, and the United Kingdom require institutions that manage medical research on humans anywhere in the world to protect research participants. Analyses of published data from six medical research projects in Africa funded by governments and other organizations in the above countries reveal HIV infections statistically linked to participation in research. Given this evidence, regulations and guidelines obligate institutions that fund, manage, or regulate these projects to investigate to determine if invasive procedures in research clinics infected participants. Findings from such investigations could have a broad and beneficial impact on health care safety in Africa.

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.

How much do blood exposures contribute to HIV prevalence in female sex workers in sub-Saharan Africa, Thailand and India?

Female sex workers (FSWs) are subject to frequent invasive procedures in health care and cosmetic services. When infection control is deficient, these procedures not only put FSWs at risk to acquire HIV, but are also risks for FSWs to transmit HIV to the general population. Direct information about blood exposures other than injection drug use as risks for HIV infection in FSWs has been too limited to test the hypothesis that unsterile health-care procedures have infected large numbers of FSWs in sub-Saharan Africa and Asia. However, indirect evidence suggests that blood exposures might account for an important proportion of their HIV infections. This indirect evidence includes: higher prevalence of hepatitis C infection among sex workers than among other women; continuing HIV acquisition among FSWs despite high rates of condom use and surprisingly high ratios of incidence of HIV compared with incidence of syphilis, gonorrhoea and chlamydia.

Routes of HIV transmission in India: assessing the reliability of information from AIDS case surveillance.

India's AIDS case surveillance system attributes 86% of HIV infections to sexual risks, 2.4% to injection drug use, 2.0% to blood transfusions, 3.6% to perinatal transmission, and 6.0% to others or not specified. To assess the reliability of this information, we examined the process of AIDS case surveillance in four high HIV-prevalence districts in southern India. We reviewed forms and interviewed doctors, counsellors, officials of State AIDS Control Societies, and a convenience sample of people living with HIV/AIDS. Current surveillance practices are not sensitive to parenteral exposures; forms have no space to report blood exposures other than transfusions and injections, and counsellors often ignore parenteral risks. The system does not distinguish high from lower risk sexual behaviours; all cases with sexual risks are reported in one category. We propose changes in forms and practices to improve the reliability and usefulness of information on risks from AIDS case reporting.

How much does heterosexual commercial sex contribute to India's HIV epidemic?

Through a search, we identified five models of India's HIV epidemic, all of which articulate the hypothesis that heterosexual commercial sex drives India's HIV epidemic. All five models assume more female sex workers (FSWs) than have been mapped (counted), and more than can be inferred from men's sexual behaviour. With best and highest plausible evidence-based estimates (15-20% of 300,000-700,000 FSWs are HIV-positive; FSWs have 570 client contacts per year; clients use condoms with 60-75% of FSW contacts; and the rate of HIV transmission from FSWs to clients is 0.0011-0.002 per unprotected contact), FSWs and clients account for 2-15% of HIV-infected adults, far less than model-based estimates of 44-68%. Overestimating the contribution of commercial sex to India's HIV epidemic misleads prevention programmes to ignore other risks, and promotes the stigmatizing assumption that HIV infection is a sign of immoral behaviour.

Reconnaissance assessment of risks for HIV transmission through health care and cosmetic services in India.

Available information shows frequent unsterile medical injections in India, but less is known about other invasive procedures. To assess the variety and frequency of blood exposures in health care and cosmetic services, we interviewed people living with HIV/AIDS in four districts with high HIV prevalence. Eighty percent reported from 1-300 injections in the five years before testing HIV-positive. Common lifetime exposures include dental care (31%), surgery (20%), blood tests (100%), and tattooing (47%). Through observation and interviews with doctors, dentists, and others, we found evidence for common to routine re-use of unsterilized equipment for blood tests (lancets), dental care, tattoos, and surgery. Health-care professionals and the public are misinformed about HIV survival outside the body and underestimate HIV transmission efficiency through blood exposures. The challenge to implement infection control for all invasive procedures remains undefined, while attention focuses on partial solutions, including single use of disposable syringes.

Efficiency of human immunodeficiency virus transmission through injections and other medical procedures: evidence, estimates, and unfinished business.

OBJECTIVE: To estimate the transmission efficiency of human immunodeficiency virus (HIV) through medical injections and other invasive procedures. DESIGN: We searched our own files and Medline (from 1966-2004, using the keywords ["iatrogenic" or "nosocomial" or "injections"] and "HIV") for reports of iatrogenic outbreaks worldwide, except outbreaks traced to receipt of contaminated blood or blood products. We also analyzed information from a case-control study of percutaneous exposures to healthcare workers. SETTING: Worldwide healthcare settings. EVENTS: We identified 8 iatrogenic outbreaks that met our study criteria; published information from 4 outbreaks was sufficient to estimate transmission efficiency. RESULTS: From the 4 documented iatrogenic outbreaks, we estimated that 1 iatrogenic infection occurred after 8-52 procedures involving HIV-infected persons. Although only 0.3% of healthcare workers seroconvert after percutaneous exposure, a case-control study reported that deep injuries and other risk factors collectively increased seroconversion risk by as much as 50 times. Laboratory investigations demonstrate HIV survival through time and various rinsing regimens. We estimate that the transmission efficiency in medical settings with no or grossly insufficient efforts to clean equipment ranges from 0.5% to 3% for lower risk procedures (eg, intramuscular injections) and from 10% to 20% or more for high-risk procedures. Efforts to clean equipment, short of sterilization, may cut the transmission efficiency by 0%-100%. Procedures that contaminate multidose vials may accelerate transmission efficiency. CONCLUSION: To achieve better estimates of the transmission efficiency for a range of medical procedures and settings, investigations of iatrogenic outbreaks should be accorded high priority.