[this is the 2nd of 3 parts; click here to get the complete paper]
3. In African countries where more people are aware of blood-borne risks, fewer people have HIV
During 2003-07, national surveys in 16 African countries asked people how to prevent HIV. In these surveys, the percent of adults who mentioned “avoid sharing razors/blades” as a way to prevent HIV ranged from 10% in Swaziland to almost 50% in Niger and Ethiopia. In five countries where less than 15% of adults recognized contaminated razors or blades as risks for HIV (Kenya, Lesotho, Swaziland, Tanzania, and Zimbabwe) the percentages of adults with HIV ranged from 5.6% to 26%. On the other hand, in six countries where at least 30% mentioned razors or blades (Democratic Republic of Congo [DRC], Ethiopia, Ghana, Niger, Rwanda, and Senegal) only 0.8% to 2.9% of adults were HIV-positive (Figure).
Figure: Percentages of adults with HIV vs. percentages aware of blood-borne risks
Percentage of adults with HIV vs. percentage aware of blood-to-blood risks
Note: the equation for the correlation is y = 20.2 – 0.53x. Source: For each country, the percent who say “avoiding sharing razors/blades” is the average of percents for men and women, excluding those not aware of HIV or who had been previously tested for HIV, from: Brewer DD. Knowledge of blood-borne transmission risk is inversely associated with HIV infection in sub-Saharan Africa. J Infect Dev Ctries 2011; 5: 182-198. Available at: http://jidc.org/index.php/journal/article/view/1308/518 (accessed 7 July 2011). Percentages of adults with HIV (except for DRC and Ethiopia) are for 2009 from: UNAIDS Report on the Global Epidemic 2010, available at: http://www.unaids.org/globalreport/Global_report.htm (accessed 4 July 2011); for DRC and Ethiopia these percentages are for 2007 and 2005, respectively, from national surveys available at: http://www.measuredhs.com/countries/.
4. The best available evidence from Africa says that sex accounts for less than half of HIV infections in adults
During 1987-2011, 44 studies in Africa tested interventions to protect adults from HIV and reported their results. These 44 studies followed a total of more than 120,000 adults and observed a total of 4,029 new infections. In most studies, the intervention failed – it had little or no impact on how fast people got HIV. But even though most interventions failed, these studies nevertheless provide some insights into how and why so many Africans are getting HIV.
The surest way to say how many of these 4,029 infections came from sex is to trace and test sexual partners; then, if any partners have HIV, sequence it to see if it matches HIV from the new infection. Only 4 of 44 studies did so, tracing a total of only 186 (4.6%) of 4,029 infections to sexual partners with similar HIV. Thus, according to these best criteria, we don’t know the sources of the other 95.4% of infections.
The second best way to say how many of these infections came from sex is to see how fast people with sexual risks got HIV compared to people with no sexual risks. Five of the 44 studies report rates of new HIV infections in men and/or women who did and did not report any possible sexual exposure to HIV. Here’s what they found:
- In a study among men in South Africa in 2002-05, men who reported no sex partner or 100% condom use (ie, no possible sexual exposure to HIV) got HIV at the rate of 1.11% per year compared to 1.86% for men who reported possible sexual exposure (at least one sex partner and less than 100% condom use). Having reported sexual exposures increased risk by a factor of 1.7 (= 1.86/1.11) times.
- In a similar study among men in Uganda in 2003-06, men who reported no partner or 100% condom use got HIV at the rate of 0.72% per year vs. 1.17% per year for men who reported one or more sex partners and less than 100% condom use. Having reported sexual exposures increased risk by a factor of 1.6 (= 1.17/0.72) times.
- In a trial among women in South Africa reported in 2011, 1 (20%) of 5 women who reported no sex partners during the trial got HIV compared to 97 (11%) of 884 women who reported one or more sex partners. Having reported sexual exposures reduced risk by a factor of 0.55 (= 11/20) times.
- In a trial among men and women in Zimbabwe in 1998-2003, reporting one or more vs. no sex partners over a period of 3 years increased risk to get HIV by a factor of only 1.3 among women, and by a factor of 2.5 among men.
- In a trial in Uganda in 1994-98, men and women who reported one or more sex partners over 2 years got HIV 2.7 times faster than men and women who reported no sex partners.
Combining information from all five studies, the median (middle) impact of reported sexual risk on an adult’s rate to get HIV was 1.65. This result – that possible sexual exposure to HIV fell far short of doubling his or her risk to get HIV – suggests that sex accounts for far less than half of new HIV infections among adults.
Faced with such evidence, study teams supposed that participants lied about their sexual behavior and continued to aver that most HIV came from sex. It’s also notable that study teams for most trials – 39 out of 44 – did not say how many people with new HIV infections reported no possible sexual exposures to HIV, even though most studies collected information on numbers of partners. By disbelieving and withholding evidence, study teams are in effect saying that evidence is not necessary – that they know without and even despite evidence that almost all HIV infections in Africa come from sex.
5. Many studies in Africa find HIV infections best explained by blood contacts
In 2001, UNAIDS hired Nicole Seguy to review evidence linking injections to HIV. Compiling data from all available studies that had followed HIV-negative adults to find new infections, and that had asked about and reported injections, she concluded: “contaminated injections may cause between 12% and 33% of new HIV infections” in Africa.
Seven of the 44 trials mentioned above report information on blood exposures for adults with new infections, including:
Aside from these trials, a lot of other evidence links HIV to injections and other skin-piercing risks, for example:
Much more evidence is available at: http://dontgetstuck.wordpress.com; in a history of AIDS in Africa at: https://sites.google.com/site/davidgisselquist/pointstoconsider; in selected papers by Gisselquist at: https://sites.google.com/site/davidgisselquist/selected-articles; and in many of Devon Brewer’s recent papers at: http://www.interscientific.net/pubs.html.
 Gisselquist D. Randomized controlled trials for HIV/AIDS prevention among men and women in Africa: untraced infections, unasked questions, and unreported data. SSRN 2011. Available at: http://ssrn.com/abstract=1940999 (accessed 18 September 2012).
 Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657-666.
 Karim QA, Karim SSA, Frolich JA, et al. Effectiveness and safety of tenofovir gel, an antiviral microbicide, for the prevention of HIV infection in women. Science 2010; 329: 1168-1174. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001187/ (accessed 15 September 2012).
 Ahmed S, Lutalo T, Wawer M, et al. HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS 2001; 15: 2171-2179.
 Wawer MJ, Sewankambo NK, Serwadda D, et al. Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomized community trial. Lancet 1999; 353: 525-535.
 Randerson J. WHO accused of huge HIV blunder. New Scientist, 6 December 2003, 180 (2424): 8-9.
 Watson-Jones D, Baisley K, Weiss HA, et al. Risk factors for HIV incidence in women participating in an HSV suppressive treatment trial in Tanzania. AIDS 2009; 23: 415-422.
 Auvert B, Sobngwi-Tambekou J, Taljaard D, Lagarde E, Puren A (2006) Authors’ Reply. PLoS Med 3(1): e67. Available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030067 (accessed 15 October 2012).
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005; 2(11): e298.
 Whitworth JA, Birao S, Shafer LA, et al. ‘HIV incidence and recent injections among adults in rural southwestern Uganda’, AIDS, 2007, 21: 1056-8.
 The 10 countries are: Cameroon, Ethiopia Ghana, Guinea, Kenya, Lesotho, Senegal Malawi, Rwanda, and Zimbabwe.
 Brewer DD, Roberts JM, Potterat JJ. Punctures during prenatal care associated with prevalent HIV infection in sub-Saharan African women. International Society for Sexually Transmitted Diseases Research, Seattle 2007.
 Brewer DD. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. WebmedCentral Epidemiology 2011;2(9):WMC002206. Available at: http://www.webmedcentral.com/article_view/2206 (accessed 16 January 2012).