HIV/AIDS and unsafe injection and needle transmission in Sub-Saharan Africa - part II

by John Kiwanuka Ssemakula (MD, MPH), May 14, 2003

Ever since a paper was published claiming that unsafe injections and needle practices are a significant route for the transmission of AIDS there has been controversy in the scientific establishment. But the story will just not go away, the controversy will not end. More and more evidence and research keeps coming to light supporting the claim that unsafe injections have played a significant role in spreading HIV/AIDS in Africa.

On the face of it, it seems an entirely plausible scenario. And anywhere else in the world this would not be an issue. It is accepted that transfer by unsafe use of needles, such as by injecting drug users is a common and significant route for spreading AIDS. Anywhere else but in Africa, specifically Sub-Saharan Africa.

The research has been universally rejected out of hand by the scientific establishment and international organizations such as UNAIDS and the World Health Organisation (WHO). The more evidence and research people uncover and publish about the possibility, the louder the protestations of the scientific elite.

And this of course raises the question, why is it such an outlandish possibility that such a thing could take place in Africa rejected, despite the mounting evidence that points to the contrary?

According to the WHO modeling of the epidemic with the best available information also shows that the overwhelming majority of infections are due to unsafe sex. What if the models are wrong? The WHO has previously estimated that unsafe injection practices account for about 2.5% HIV infections in sub-Saharan Africa saying "Although there is a margin of uncertainty around this estimate, the conclusion remains that unsafe sex is by far the predominant mode of transmission in sub-Saharan Africa."

The WHO/UNAIDS went on to say "The expert consultation also emphasized the importance of achieving safe and appropriate use of injections in both the formal and informal health care sectors of low and middle income countries, as in high income countries. There are an estimated 16 billion injections given globally each year, of which an estimated 30 per cent are unsafe due to the reuse of equipment.. The participants of the meeting fully agreed that safe medical injections are crucial to minimise the risk of transmission of not only HIV, but other pathogens such as hepatitis B and hepatitis C in healthcare settings, and to maintain confidence in the healthcare system."

Note the figure of 30% unsafe injection use the world over. But somehow in Africa unsafe injection use only contributes 2.5% to HIV according to their models - based on best available data. This is in Africa which of course has over burdened, under financed, under manned public health systems.

Furthermore their assertion in a press release saying that "For example, children between 5-14 years, who are generally not yet sexually active, have very low infection rates;" (Joint UNAIDS/WHO, Press statement 2003, Geneva, 14 March 2003," Expert Group Stresses That Unsafe Sex Is Primary Mode of HIV Transmission In Africa") is not supported by data coming out of South Africa which finds that children between 2-14 years have rates of HIV of almost 6% (Mandela Report HSS 2002) which is extremely high figure.

The current controversy comes at a time when the WHO and the International Community are congratulating themselves on the unprecedented response to SARS and their success at controlling the outbreak. Would that this were true for Africa!

UN, WHO and other health officials argue that if we consider such a scenario, it could have the possibility, and it become widely known, it could have the effect of undermining prevention and education campaigns in Africa. This seems to be a curious kind of logic. Instead of protecting people from the possibility of being infected due to unsafe medical practices, let's keep quiet, just in case people will decide to go out and have sex instead!

Listening to the specious and spurious arguments being put forward by people who should know better, it seems that the conclusion is Africans should settle for the choice if unsafe inadequate health care or no health care at all, if only to protect the accepted establishment position that prevention and changing sexual behaviour is the only means to fight the HIV/AIDS epidemic.

Let's be quite clear about this it is not science fiction we are talking about here. It is not even scientific speculation because needle transmission of HIV has been proven the world over. Accepting the possibility that it could and has occurred in Africa, would serve to bring Africa's HIV epidemic in line with the rest of the world, and stop the endless speculation of why Africa's epidemic is so different. It would also sit in with all other studies that have found the virus is no more virulent or that apart form poverty, the conditions in Africa are not so different to account for the rate of spread. At the very least it behooves one to at least do some research to either prove or disprove the theory.

But when all is said and done, the fact is what is really at stake here is providing safe health care to Africans. So no matter how small the possibility that unsafe injection may be contributing to HIV/AIDS, it is incumbent upon health and policy planners to deal with this issue. Doing nothing or denying the possibility does not sit well with the stated aims of proving accessible, equitable, affordable health care of a high standard to all people. Indeed it is a human right. At the most basic level, safe quality health care is a right for all people. This is what the WHO and UN should be aiming to attain, the same standards of healthcare for all Africans as in the rest of the world.