Mode of transmission of HIV-1 in Saudi Arabia

The mode of HIV-1 transmission was determined for 410 Saudi patients. Heterosexual transmission occurred in 189 patients (46%), blood product transfusion in 107 (26%), and perinatal transmission in 47 (12%). Men who have sex with men and injection drug users represented 5% and 2%, respectively. Sixty-three of 65 heterosexually infected women acquired HIV-1 from their spouses, whereas 111 of 124 heterosexually infected men acquired the virus from commercial sex workers. Heterosexual transmission is the main mode in Saudi patients.

Data on HIV transmission are scarce from countries of the eastern Mediterranean region of the World Health Organization including Saudi Arabia. Although 11 699 AIDS cases and 33 943 HIV cases were reported in the region up to October 2002, there was no estimate for Saudi Arabia [¹]. The King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia is the major HIV referral and care centre for the country. HIV-infected patients are referred for counseling, assessment and treatment. We undertook this study to identify the various modes of transmission of HIV-1 among infected individuals.

All patients diagnosed with or cared for for HIV infection and its complications between 1984 and 2003 were included. The mode of transmission of HIV-1 was determined by the primary provider from clinical data and patient history. The modes of transmission of HIV were adapted from UNAIDS [²]. For the purpose of this report they are: haemophilia (coagulation factors concentrate transfusion), heterosexual transmission, men who have sex with men (MSM), injection drug use (IDU), blood and blood product transfusion, organ transplantation, and perinatal transmission. For statistical analysis, the t-test was used to calculate continuous variables and χ² was used for proportions. All reported P values are two-tailed, and a value of 0.05 or less was considered significant.

A total of 410 Saudi patients constitute the study population for this report. The mean age at diagnosis was 27.8 years [95% confidence interval (CI) 26.3–29.3] and median 28 years (range 1–92). Women were significantly younger than men at diagnosis, a mean of 25.5 (SD ± 14.6) years versus 29 (SD ± 15.7) years for men, P < 0.04. The modes of transmission for men and women are detailed in Table 1. Most heterosexually infected women (63/65, 97%) acquired the virus from their husbands, whereas 13 of the 124 heterosexually infected men (10%) acquired the virus from their wives. Six patients acquired HIV after kidney transplantation. Two received cadaveric kidneys in the United States in 1985, four received the kidneys from commercial living non-related donors in India and Egypt. Finally, two patients were grouped separately to the others. A male sexual abuse victim acquired the virus from his rapist. The other patient acquired HIV from a contaminated device for hijjamah (traditional medicine of applying glass cupping and skin scarification).

Table 1: Mode of transmission of HIV.

The incidence of HIV infection among adults in the Middle East is estimated to be 0.3%, but increased by 20% during 2002 [³]. In Saudi Arabia, the cumulative number of HIV-infected individuals was estimated at 1100 in 2000, with an adult rate of 0.01% [²]. Our institution is the main national facility for HIV care, offering unlimited access for HIV-infected individuals who could be self-referred for voluntary counseling and testing.

Although HIV acquisition was predominantly through blood products initially, increasing numbers of individuals from this part of the world acquire the virus heterosexually, similar to other developing countries [⁴]. We anticipated that the mode of transmission would be different for men and women. Nevertheless, almost half of the infected men and women acquired the virus heterosexually. For men, the source was a female sex worker but for women the source was their spouse. The source of HIV-1 in concordant infected couples was ascertained by confirming the infection in the husband from other risk factors (e.g. haemophilia), determining the preceding infection by a lower CD4 T lymphocyte count compared with the wife, and the absence of other risk factors for acquiring HIV-1 in the wife. These requirements were satisfied in the 13 couples in whom the wife infected the husband. Similar to other areas, women seem to be vulnerable to HIV infection, not because of risky behaviour but because of the role of women in the communities [⁵].

A major difference between our patients and HIV-infected individuals from the neighboring Islamic Republic of Iran is the limited role of IDU as a mode of transmission for HIV [⁴]. Studies in injecting drug users from Saudi Arabia have indicated an HIV prevalence of 0.15% [⁶]. Injecting drug users are routinely screened for HIV in all drug treatment centres. Once positive, these patients are referred to our facility for HIV care. Therefore, the low rate of IDU among our HIV population (2%) is a reflection of the so far low prevalence of HIV in the IDU community in Saudi Arabia.

Blood and blood product transfusion seem to have contributed the majority of HIV infections early in the HIV epidemic. We elected to separate haemophiliac patients because of the higher risk of HIV infection because of coagulation factors concentrate and repeated transfusions. Saudi Arabia used to import blood and blood products. The first published reports on AIDS from the region were related to the transfusion of imported blood [^7,8]. Subsequently, imported blood has resulted in an outbreak of HIV infection. In one regional hospital serving a population of 0.4 million people, 25 cases of HIV infection were confirmed to have resulted from blood and blood products transfusion [⁹]. In another report [¹⁰], five out of 212 multitransfused thalassaemic patients (or 2.5%) were HIV positive. Both reports cited imported blood, before HIV screening, as the source of infection.

MSM were not a significant group in our cohort. This could be related to an actual low prevalence of HIV-1 in gay Saudi men or a misidentification because of local perceptions about homosexuality, or both. MSM may not express their sex orientation freely in a community such as Saudi Arabia.

Commercial kidney transplantation continues to be a better option than haemodialysis for many patients in this country [¹¹]. Living unrelated kidney donation is illegal in Saudi Arabia; therefore patients travel to other countries to buy the kidney, resulting in HIV infection reaching up to 4.3%. Out of 540 Saudi haemodialysis patients who received a commercial kidney transplant from India, 23 have acquired HIV-1. HIV infection among those commercial kidney transplant recipients was associated with poor survival [¹²].

The potential limitation of our study is that it comes from a single centre. However, as the main referral centre for HIV patients, our patient population represents the majority of diagnosed HIV-infected individuals. The absence of surveillance data on HIV-1 would give reports such as ours a chance to present the limited available data on HIV transmission modes. These data argue that there is an urgent and pressing need for a national HIV sentinel surveillance programme in well-defined groups. We believe that general adult prevalence rates are low and would not exceed the estimates of UNAIDS of 0.01% [²].

In conclusion, heterosexual transmission is the main mode of acquiring HIV-1 among Saudi patients. Women acquire the virus from their spouses, whereas heterosexually infected men acquired it from extramarital sex. Other vulnerable groups remain less defined in this community, therefore low rates may not be reflective of actual prevalence rates in groups such as MSM and IDU.