A PUBLICATION OF THE POPULATION AND DEVELOPMENT PROGRAM AT HAMPSHIRE COLLEGE NO.

7 ~ FALL 2000

Viral Roulette:Malaria,Blood, and AIDS in Sub-Saharan Africa

by Stephen F. Minkin AIDS epidemic will continue out of control until we pull our heads out of the sand and recognize that people are exposed to the risk of HIV infection In a speech in Abuja, Nigeria on August 27th, President Clinton came very close to identifying a taboo subject - the medical transmission of HIV. Mr. Clinton noted that both AIDS and malaria are increasing in Nigeria, but his staff failed to advise him on how the two killers are connected: Malaria causes life-threatening anemia often requiring transfusions. Contaminated blood transfusions are the most efficient means of HIV transmission. Imagine AIDS in the United States if we had ignored the potential for hospitals and clinics to become centers of HIV infection. Suppose we highThe President talked about the need for open and frank discussions about AIDS. Openness about AIDS in Africa as elsewhere should not only be limited to discussions about sex.The lighted condoms and sex education but were haphazard in the application of universal precautions and blood screening. Suppose our hospitals and clinics played viral roulette by sometimes using sterile equipment but often reusing unsterile syringes, needles, catheters, specula and other invasive equipment over and over again. Under these circumstances AIDS in the U.S. and Africa would look more similar.The U.S. would have an overwhelming health problem, with large numbers of women and children dying from AIDS. The United States has been most successful in fighting AIDS at home by preventing the spread of HIV infection in hospitals and clinics. We invested heavily in universal precautions, reduced the use of transfusions and screened all blood and blood products for HIV. Poor Africans are being told to fight AIDS without the benefit of these wise investments. in overburdened clinics and hospitals without sufficient resources to ensure sterile procedures and safe blood.

c/o Population & Development Program Hampshire College-CLPP Amherst, MA 01002-5001 USA 413/559-6046 fax 413/559-6045 http://hamp.hampshire.edu/~clpp/popdev.html Opinions expressed in this publication are those of the individual authors unless otherwise specified.

Africans today are enduring an experiment comparable to the notorious Tuskegee Experiment that denied treatment to hundreds of African American men infected with syphilis, a curable disease, for forty years. Now millions of vulnerable Africans are denied access to HIV-free blood and to health care that we take for granted. In Tuskegee then and Africa today a major reason for the denial of standard care is white peoples

assumptions about black peoples sex lives and health. Surely, AIDS is sexually transmitted in Africa, but as in the United States there is much more to the story than sex alone. In Tuskegee the denial of treatment was deliberate. In Africa the devil is negligence by internationally funded AIDS programs.

blood donors is also on the increase, to the extent that safe blood has become a scarce and rare commodity.
In the U.S. the greatest risk of HIV infection for heterosexuals is among people using unsterile needles or women whose sex partners use unsterile needles. In this country people infected by needles are called junkies or IV drug users. In Africa they are called patients.The October 1999 World Health Organization Bulletin reported that over 50 percent of injections

African women and young children are most vulnerable to medically transmitted HIV infections. Women of reproductive age get more injections and invasive examinations than other demographic groups.They start having children earlier and have more children than Americans. They need more life-saving transfusions for childbirth complications and for pregnancyrelated anemia.They are also placed at risk because of medically questionable injections and transfusions. A vexing problem is to ensure that they get blood when they need it without exposing them to HIV, Hepatitis B or C, and other diseases.This will require investments in training, salaries and equipment.

were unsafe in African countries for which data were available.

UNAIDS estimates that 5-10 percent of global HIV infections are directly related to blood. Even if we accept these minimal figures, their significance for AIDS prevention in Africa is much greater. Investing in AIDS without plugging this hole is like pouring water in a bottomless bucket. Without safe health care, much of the future spending on AIDS in Africa will be both ethically dubious and ineffective.

The proportions of HIV infection resulting from sex or other causes are not known. A recent large perspective study in Rakai, Uganda published in the journal AIDS indicates that that a great deal of previous work on AIDS in Africa was at best incomplete or drew sloppy conclusions.The study found that people became HIV-positive regardless of their history of exposure to sexually transmitted diseases (STDs).The Uganda research follows earlier studies showing that many or most HIV-positive women at

The problem of pregnancy-related anemia is most serious in areas with endemic malaria. During pregnancy women lose much of their immunity to the disease.The problem is compounded by poor diet and the numerous stresses caused by poverty. Likewise young children who have not yet developed immunity to malaria fall ill and often need blood.

outpatient or maternity clinics had no previous history of sexually transmitted diseases. Such findings run contrary to the viewpoint that STDs and promiscuity alone account for the fact that Africans are so vulnerable to HIV/AIDS.

Some donor countries are doing much more than the United States to protect people from HIV infection in hospitals and clinics.The German agency GTZ has taken a leadership role by supporting blood screening in the Congo. However, the U.S., the leading global source for AIDS preven-

The following comments by Charles Obonyo, a Kenyan physician, highlight a reality ignored by experts and the media covering AIDS:

tion funds, has so far paid scant attention to the problem. As the major donor, the U.S. virtually calls the shots at both the World Bank and UNAIDS.This gives Mr. Clinton and his successor the opportunity and responsibility to ensure that future investments are both ethically viable

It has become clear in recent years that the prevalence of severe pediatric anemia requiring blood transfusion, particularly in malariaendemic regions, has markedly increased. At the same time, the prevalence of HIV among

and effective.

Stephen F. Minkin is a Coordinator for the Network for Infection Prevention (NIP). NIP is an Internet based coalition concerned with reducing the spread of HIV and other diseases from transfusions, injections and invasive medical procedures. NIP believes that access to safe health care is a human right requiring investments and training in medical hygiene. Steve is currently writing a book entitled
The Missing History of AIDS. He lives in

Suggested Readings:

Nafissatou, et al, Increased Susceptibility to Malaria During Early Postpartum Period, New England Journal of Medicine; 343, August 31 2000, (pp. 598-603).

Minkin SF, Comments in Packard RM and Epstein P, Epidemiologists, Social Scientists and the Structure of Medical Research on AIDS in Africa, Social Science and Medicine; 33:7, 1991, (pp. 786-790) . Minkin SF, AIDS in the 21st century, New England Journal of

Brattleboro, Vermont.
The NIP web site address is: www. Africa-HIV.org. Please e-mail comments to: niphiv@yahoo.com or write to: P Box 6073, Brattleboro, VT 05302 .O.

Medicine; 342, February 2000, (pp. 516-517).