HIV Transmission in Africa

“Sera were obtained from 2103 South African individuals (862 miners, 95 sex workers, 731 female and 415 male township residents; mean age 33.2 years). All sera were tested for antibodies to KSHV [Kaposi’s Sarcoma Herpes Virus, believed by some to be the cause of this skin cancer or cancer-like condition]…, HIV, gonococcus, herpes simplex virus type 2 (HSV-2), syphilis and chlamydia. Information on social, demographic and high-risk sexual behavior was linked to laboratory data…Overall KSHV and HIV prevalences were 47.5% and 40%, respectively…No significant difference in KSHV infection was observed among the residential groups. KSHV was not associated with any of the STI or any measures of sexual behavior…KSHV was also associated with drinking alcohol at least once a day (OR 1.4, 95% CI 1.0–2.1). Unexpectedly, male subjects who were circumcised were at a 1.3-fold risk of being KSHV infected than uncircumcised men”

“During 5253 person-years at risk, 170 individuals [in an area of rural South Africa] became seropositive. The crude HIV incidence rate [new conversions to HIV seropositivity] per 100 person-years was 3.8 in women aged 15–49 years and 2.3 in men aged 15– 54 years.”

“Latest statistics from the Uganda HIV/Aids Sero-behavioural Survey indicates that 7.9 per cent of women have HIV/Aids compared to only six per cent men.”

“As far as biology is concerned, says Stillwaggon [a US academic], the immune systems of people in southern Africa are weakened by malnutrition and parasitic illnesses.

First, malnutrition - a deficiency of energy, protein and minerals such as iron, zinc and vitamins - makes a person far more susceptible to infectious and parasitic diseases.

These deficiencies make it hard for new cells to be built, including CD4 cells that protect the body from infections.

A malnourished person usually has a high viral load because they have few resources in their body to combat the virus. People with higher viral loads are much more infectious, thus making their partners far more susceptible to getting HIV.

Malaria, bilharzia and intestinal worms also drive up a person’s viral load.”

“Poverty and lack of economic opportunity are commonly cited as important contributors to the AIDS epidemic. Indeed an essay in The Lancet last year asked whether poverty reduction was the only sustainable solution to preventing AIDS. Thus recent findings from the Tanzania 2003–04 HIV/AIDS indicator survey may come as a surprise. The evidence is just the opposite…Household wealth is strongly positively related to HIV prevalence. Indeed the difference in prevalence for women between the lowest and highest wealth quintile is four-fold [the richest 20% of women have four times the risk of being HIV-positive compared with the poorest 20%]. These findings are similar to those reported for Kenya last year. Notably, HIV prevalence is highest in some of the most economically advanced countries in Africa (eg, South Africa, Botswana). A positive relation between wealth and HIV risk has been noted before, but has been upstaged by the focus on poverty. [This is blamed on richer people having more concurrent sexual partners, although the evidence for a dramatic difference appears weak]”

“The Women's Health Study of Accra is a cross-sectional study designed to measure the burden of communicable and noncommunicable diseases in adult women residing in Accra, Ghana. This study assessed the prevalence rate of HIV and risk factors associated with HIV infection in 1,328 women age 18 years and older. The weighted overall HIV prevalence rate for women residing in Accra is 3.1%…In addition to young age [especially 25-29 years old], other significant risk factors included sexually transmitted infection (STI) symptoms and mean number of lifetime sexual partners. All HIV-positive women were sexually active. Other findings significantly associated with HIV-positive status included chills, oral lesions, tuberculosis, bloody sputum production, and intestinal parasite infections. There was a significant association with HIV-positive status and locality of residence in the city. There was no association with reported use of condoms, blood transfusions, surgery, reproductive health history including pregnancy or number of sexual partners, symptoms suggestive of AIDS, or self-perception of health. There was also no association with education level, religion, ethnicity, marital status, or socioeconomic level.”

“After 20 years of research to elucidate patterns of HIV transmission in sub-Saharan Africa, epidemiologists have failed to identify even a single sexual variable that is an important personal risk for HIV acquisition and that is consistently higher in communities with higher HIV prevalence. The scope of this failure is staggering when one considers not only the substantial resources that have been expended to this enterprise, but also the large differences between epidemic trajectories in Africa. Whatever is causing these differences should not be so elusive. Failure makes sense if one considers that a substantial proportion of HIV transmission in Africa must not be mediated by sexual contact…We recommend enlarging the list of risk factors to include evaluation of blood exposures in (especially sex-related) health care, of scarification, and of other sexual variables, especially anal intercourse.”

“In 1988, prominent organizations and experts circulated estimates attributing about 90% of HIV infections in African adults to heterosexual contact. Estimates have inched upwards since. According to the World Health Organization’s 2002 World Health Report, ‘current estimates suggest that more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex’…We have been unable to locate any document - from the 1980s or later - that describers a process to estimate a 90% sexual contribution to Africa’s HIV epidemic from empirical studies of risk factors for HIV…With two estimates of non-marital sexual transmission, total sexual transmission from women to men accounts for 30–35% of HIV incidence in men [and man to woman sexual transmission accounts for only 25-29% of HIV incidence in women]”

“Overall, 26% of individuals in Kisumu and 28% in Ndola were HIV-positive. In both sites, HIV prevalence in women was six times that in men among sexually active 1 5-19 year olds, three times that in men among 20-24 year olds, and equal to that in men among 25-49 year olds. Age at sexual debut was similar in men and women, and men had more partners than women. Women married younger than men and marriage was a risk factor for HIV, but the disparity in HIV prevalence was present in both married and unmarried individuals. Women often had older partners, and men rarely had partners much older than themselves. Nevertheless, the estimated prevalence of HIV in the partners of unmarried men aged under 20 was as high as that for unmarried women. HIV prevalence was very high even among women reporting one lifetime partner and few episodes of sexual intercourse…Behavioural factors could not fully explain the discrepancy in HIV prevalence between men and women. Despite the tendency for women to have older partners, young men were at least as likely to encounter an HIV-infected partner as young women.”

“Although the subjects in our study [in the ‘squalid’ village of Rakai, Uganda] deny overt promiscous behaviour, their sexual behaviour is, by Western standards, heterosexually promiscuous [no evidence for this given]”

“of the 11 HTLV-III[HIV]-positive sera, 8 were collected from females and 3 from males. The highest proportion of confirmed seropositive subjects was observed in the 21 to 40 year age group, in which the only positive donors were female.”