Last Friday (14th March) the World Health Organisation (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) hosted an expert consultation which addressed issues related to unsafe injection practices and HIV in healthcare contexts and evaluated the relative contribution of unsafe injections to HIV transmission in sub-Saharan Africa.
Following a review of evidence, which included recent articles suggesting that a majority of HIV infections in sub-Saharan Africa are due to unsafe medical practices, particularly injections, the experts concluded that such suggestions are not supported by the vast majority of evidence and that unsafe sexual practices continue to be responsible for the overwhelming majority of HIV infections. While a combination of prevention measures are required to tackle all modes of HIV transmission, safer sex promotion must remain the primary feature of prevention programmes in the region.
This position is strongly supported by epidemiological and biomedical data. For example, children between 5-14 years, who are generally not yet sexually active, have very low infection rates; age-specific infection rates among young women and men strongly follow patterns of sexual behaviour and those of other sexually transmitted infections (such as herpes simplex virus-2); in sexually active couples both partners are often infected; and, there is no consistent association between higher HIV rates and lower injection safety standards.
Modelling of the epidemic with the best available information also shows that the overwhelming majority of infections are due to unsafe sex. WHO has previously estimated that unsafe injection practices account for about 2.5% of HIV infections in sub-Saharan Africa. 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.
Research published recently in the International Journal of STD & AIDS claims that only one-third of HIV cases have been transmitted via unsafe heterosexual sex, while unsafe medical practices, such as injections and blood transfusions using unsterile needles, have proved to be a much greater risk.
Professor Michael Adler of University College London Medical School was reported in the British Medical Journal on March 1 as saying:"It’s true there was a problem with infected needles in the 1980s, but it was nowhere near as big a factor as they suggest. If that many needles were dirty, we’d be seeing far higher rates of hepatitis than we are, because hepatitis is much more easily transmitted by injection than HIV."
With approximately 3.5 million Africans becoming infected in 2002 alone, and a total of 29.4 million adults and children living with HIV/AIDS in the region, the prevention of HIV through the practice of safer sex should be the mainstay of the response to AIDS in the region.
The expert consultation also emphasised 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.
Reference
Dyer, O. Spread of AIDS in Africa driven by poor medical practice, report says BMJ 2003;326:466 ( 1 March ).
WHO/UNAIDS Press Release Expert group stresses that unsafe sex is primary mode of HIV transmision in Africa.