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Expert group stresses that unsafe sex is primary mode of transmission of HIV in Africa

An expert group has reaffirmed that unsafe sexual practices are responsible for the vast majority of HIV infections in sub-Saharan Africa, and that safer sex promotion must remain the primary feature of prevention programmes in the region.

Today the WHO and UNAIDS hosted an expert consultation which addressed issues related to unsafe injection practices and HIV in healthcare contexts and evaluated the relative contribution of unsafe injections to HIV transmission in sub-Saharan Africa.

Following a review of evidence, which included recent articles suggesting that a majority of HIV infections in sub-Saharan Africa are due to unsafe medical practices, particularly injections, the experts concluded that such suggestions are not supported by the vast majority of evidence and that unsafe sexual practices continue to be responsible for the overwhelming majority of infections. While a combination of prevention measures are required to tackle all modes of HIV transmission, safer sex promotion must remain the primary feature of prevention programmes in the region.

This position is strongly supported by epidemiological and biomedical data. For example, children between 5-14 years, who are generally not yet sexually active, have very low infection rates; age-specific infection rates among young women and men strongly follow patterns of sexual behaviour and those of other sexually transmitted infections (such as herpes simplex virus-2); in sexually active couples both partners are often infected; and, there is no consistent association between higher HIV rates and lower injection safety standards.

Modelling of the epidemic with the best available information also shows that the overwhelming majority of infections are due to unsafe sex. WHO has previously estimated that unsafe injection practices account for about 2.5% of HIV infections in sub-Saharan Africa. Although there is a margin of uncertainty around this estimate, the conclusion remains that unsafe sex is by far the predominant mode of transmission in sub-Saharan Africa.

With approximately 3.5 million Africans becoming infected in 2002 alone, and a total of 29.4 million adults and children living with HIV/AIDS in the region, the prevention of HIV through the practice of safer sex should be the mainstay of the response to AIDS in the region. Discussions about the importance of other modes of transmission should at no time weaken this central part of the response.

The expert consultation also emphasized the importance of achieving safe and appropriate use of injections in both the formal and informal health care sectors of low and middle income countries, as in high income countries. There are an estimated 16 billion injections given globally each year, of which an estimated 30 per cent are unsafe due to the reuse of equipment. The participants of the meeting fully agreed that safe medical injections are crucial to minimise the risk of transmission of not only HIV, but other pathogens such as hepatitis B and hepatitis C in healthcare settings, and to maintain confidence in the healthcare system.

Injections are vital for immunization programmes and for the provision of life-saving treatment. Injections should be used only when medically necessary, and should be given using single use equipment which is then disposed of safely. In the past several years, major efforts and resources have been devoted to enhancing injection safety in the healthcare setting through better planning of services including immunization, training of care providers and vaccinators, provision of single-use injection equipment and proper ‘sharps’ disposal. More needs to be done to eliminate unsafe injection practices throughout the world. To further this work, WHO has just issued a framework to assist countries with all aspects of the provision of safe injections, entitled “Managing an Injection Safety Policy”.

In the context of the AIDS epidemic, WHO and UNAIDS continue to strive to understand the global and local epidemiology of HIV, consider new information as it arises, and provide leadership to prevent HIV infection from all sources, including unsafe sex, mother-to-child transmission, blood and blood products and unsafe injections.

For more information, please contact Dominique de Santis, UNAIDS, Geneva, (+41 22) 791 4509 or (+41 79) 254 6803 (mobile), Andrew Shih, UNAIDS, New York, (+ 1 212) 584 5012, or Chris Powell, WHO, Geneva, (+41 22) 791 2888 or (+41 79) 217 3425 (mobile) or Christine McNab, WHO, Geneva, (+41 22) 791 4688; (+41 79) 254 6815 (mobile)