Unsterilised needles in Africa

The World Health Organization (WHO) estimates that worldwide, about 5% of HIV infections come from the use of unsterilised needles.

In a series of papers published in 2002 and 2003, STI specialists David Gisselquist and John Potterat and psychologist Stuart Brody caused controversy by claiming that between 35 and 65% of HIV infections in Africa were caused by reuse of unsterilised needles rather than sex.¹

Gisselquist and colleagues based their theory on an analysis of early HIV infection reports received from countries in east and central Africa before 1990. They claimed to show that the number of medical injections reported by seroconverters were much better correlated with HIV infection than the number of sexual partners or STIs they had had.

Gisselquist also cited a South African study which found significant levels of HIV infection in children born to HIV-negative mothers, and evidence from Zimbabwe that falling STI rates were accompanied by rising HIV rates.

The work of Gisselquist and colleagues created enough controversy for the WHO to make an investigation of their theory. In an article published in The Lancet they reviewed Gisselquist and colleagues’ arguments and refuted them:²

• Transmission via unsterilised needles may possibly have contributed to the spread of HIV early on in the epidemic but Gisselquist had failed to review data since 1990 which showed an overwhelming lack of correlation between injections and HIV seropositivity.³
• Gisselquist was using ‘reverse causality’; patients with HIV had had more injections because they had HIV-related illnesses, not HIV because they had injections.
• The South African study which found high rates of HIV infection in children of HIV-negative mothers was flawed, as the study authors admitted at the time; it had relied on oral HIV swabs self-administered by families and there was a lot of cross-contamination.
• More than twice as many injections with unsterilised needles are given in Asia (where the practice of getting vitamin shots from street-corner stalls is widespread) than in Africa. If HIV was largely spread by needles rather than sex, India would have the world’s highest HIV prevalence.
• HIV has continued to increase in Zimbabwe and some other southern African countries as STIs have decreased because HIV prevalence is so high that most HIV infection is now occurring within marriage, where bacterial STIs are less likely to be commonly transmitted.