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Let it be sexual: how health care transmission of AIDS in Africa was ignored.

Let it be sexual: how health care transmission of AIDS in Africa was ignored. David Gisselquist,John J Potterat,StuartBrody and Francois Vachon International Journal of STD & AIDS 2003; 14: 148-161
Abstract / Summary: 
Summary: The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in African adults emerged no later than 1988. We examine evidence available through 1988, including risk measures associating HIV with sexual behaviour, health care, and socioeconomic variables, HIV in children, and risks for HIV in prostitutes and STD patients. Evidence permits the interpretation that health care exposures caused more HIV than sexual transmission. In general population studies, crude risk measures associate more than half of HIV infections in adults with health care exposures. Early studies did not resolve questions about direction of causation (between injections and HIV) and confound (between injections and STD). Preconceptions about African sexuality and a desire to maintain public trust in health care may have encouraged discounting of evidence. We urge renewed, evidence-based, investigations into the proportion of African HIV from non-sexual exposures. Why was evidence ignored?  
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It has been said that people often see what they wish to see. Papers published around 1988 reveal a number of considerations that might have encouraged a mindset prepared to see heterosexual transmission as the driving force in Africa’s HIV epidemic. First, it was in the interests of AIDS researchers in developed countries—where HIV seemed stubbornly confined to MSMs, IDUs, and their partners—to present AIDS in Africa as a heterosexual epidemic; ‘nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS’ (quoted from p. 51383). In a prominent 1988 article in Science, Piot and colleagues generalize with arguably more public relations savvy than evidence that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’10. Second, there may have been an inclination to
emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing programmes and efforts to curb Africa’s rapid population growth. Third, ‘the role of sexual promiscuity in the spread of AIDs in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans’, as Packard and Epstein document in a regrettably ignored 1991 article84. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—eg, to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’85. In short, tangential, opportunistic, and irrational considerations may have contributed to ignoring and misinterpreting epidemiologic evidence.

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David Gisselquist,John J Potterat,StuartBrody and Francois Vachon

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