JAIDS Journal of Acquired Immune Deficiency Syndromes:
Letters to the Editor
*School of Social Sciences, University of Paisley, Scotland, United Kingdom, †Interdisciplinary Scientific Research, Seattle, WA, ‡Independent Consultant, Colorado Springs, CO
To the Editor:
Meier and colleagues' recent report1 reveals an association of HIV infection in Kenyan men with receipt of medical treatment for serious illness (adjusted odds ratio [OR] = 5.1) and poor genital hygiene (adjusted OR = 0.41 for an index derived from behaviors including frequency and extent of bathing and bathing after sex). The authors interpret the latter result as a consequence of better hygiene reducing the risk of conventional sexually transmitted infections, which, in turn, presumably reduces the risk of sexually acquired HIV. Surprisingly, the authors neither discuss the strong association of prevalent HIV infection with having been “ever treated for a serious illness” nor clarify this variable's content.
Although we heartily endorse the authors' support for good genital hygiene, we also note that their results are consistent with the burgeoning evidence2-9 for a key role that iatrogenic transmission probably plays in the propagation of HIV in sub-Saharan Africa and other regions with similar epidemiologic characteristics. In sub-Saharan Africa, HIV infection has been more strongly associated with treatment for sexually transmitted infections than with untreated sexually transmitted infections.5 Inadequate genital hygiene can readily lead to inflammation,10 which can lead to seeking treatment in formal or informal medical settings. Injection treatment is frequently demanded by patients in Africa or is administered by providers who think their patients expect injections, even when not medically necessary or appropriate.11 Medical injections have been consistently associated with HIV transmission in many regions with poor medical hygiene.3,5,9,12
With cross-sectional data, it can be difficult to infer whether health care-related blood exposures involve HIV transmission or whether HIV-associated illnesses occasion health care-related blood exposures. The available evidence indicates that most of the cross-sectional association between medical injections and HIV infection may be attributable to injections received before the onset of HIV-related symptoms or illnesses. With perhaps a single exception,13,14 medical injections have been repeatedly associated with incident HIV infection in sub-Saharan Africa.5,12,15,16 Also, in a large sample of Zambian women without symptoms or signs of HIV infection, medical injections was the strongest correlate of HIV infection and presumed sexual risk behaviors were only weakly, and often inversely, associated with HIV prevalence.3 Furthermore, a history of tetanus immunization during pregnancy was related to prevalent HIV infection in a national probability sample of Kenyan women; sexual behaviors were uncorrelated with HIV infection.9 The purely prophylactic nature of the tetanus injections largely eliminates the possibility that injections were sought as a result of illness (reverse causality).
Meier and colleagues' “unexpected” results highlight the need to assess the full range of exposures and use research designs tailored to the investigation of infectious disease for elucidating routes of HIV transmission, especially in poor countries.17,18
Stuart Brody, PhD*
Devon D. Brewer, PhD†
John J. Potterat, BA‡
*School of Social Sciences University of Paisley Scotland, United Kingdom
†Interdisciplinary Scientific Research Seattle, WA
‡Independent Consultant Colorado Springs, CO
1. Meier AS, Bukusi EA, Cohen CR, et al. Independent association of hygiene, socioeconomic status, and circumcision with reduced risk of HIV infection among Kenyan men. J Acquir Immune Defic Syndr. 2006;43;117-118.
2. Brody S. Declining HIV rates in Uganda: due to cleaner needles, not abstinence or condoms. Int J STD AIDS. 2004;15:440-441.
3. St. Lawrence JS, Klaskala W, Kankasa C, et al. Factors associated with HIV prevalence in a pre-partum cohort of Zambian women. Int J STD AIDS. 2006;17:607-613.
4. Potterat JJ, Brody S. HIV epidemicity in context of STI declines: a telling discordance. Sex Transm Infect. 2002;78:467.
5. Gisselquist D, Potterat JJ, Brody S, et al. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS. 2003;14:148-161.
6. Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS. 2003;14:144-147.
7. Apetrei C, Becker J, Metzger M, et al. Potential for HIV transmission through unsafe injections. AIDS. 2006;20:1074-1076.
8. Becker ML, Ramesh B, Moses S, et al. Response to Brewer et al regarding our article ‘Association between medical injections and HIV infection in a community based study in India.’ AIDS. 2006;20:1209.
9. Deuchert E, Brody S. The role of health care in the spread of HIV/AIDS in Africa: evidence from Kenya. Int J STD AIDS. 2006;17:749-752.
10. Krueger H, Osborn L. Effects of hygiene among the uncircumcised. J Fam Pract. 1986;22:353-355.
11. Drucker E, Alcabes PG, Marx PA. The injection century: massive unsterile injections and the emergence of human pathogens. Lancet. 2001;358:1989-1992.
12. Gisselquist D, Potterat JJ. Review of evidence from risk factor analyses associating HIV infection in African adults with medical injections and multiple sexual partners. Int J STD AIDS. 2004;15:222-233.
13. Brody S, Potterat JJ. HIV epidemiology in Africa: weak variables and tendentiousness generate wobbly conclusions. PloS Med. 2005;2:e137.
14. Lopman BA, Garnett GP, Mason PR, et al. Individual level injection history: a lack of association with HIV incidence in rural Zimbabwe. PloS Med. 2005;2:142-146
15. Todd J, Grosskurth H, Changalucha J, et al. Risk factors influencing HIV infection incidence in a rural African population: a nested case-control study. J Infect Dis. 2006;193:458-466.
16. Todd J, Grosskurth H, Hayes R. Reply to Gisselquist. J Infect Dis. 2006;194:537-538.
17. Brewer DD, Hagan H, Sullivan DG, et al. Social structural and behavioral underpinnings of hyperendemic Hepatitis C virus transmission in drug injectors. J Infect Dis. 2005;194:764-772.
18. Brody S, Potterat JJ. Establishing valid AIDS monitoring and research in countries with generalized epidemics. Int J STD AIDS. 2004;15:1-6.
© 2007 Lippincott Williams & Wilkins, Inc.