HIV This Week

de Walque D. Do unsafe tetanus toxoid injections play a significant role in the transmission of HIV/AIDS? Evidence from seven African countries. Sex Transm Infect. 2008 ;84(2):122-5.

Although sexual transmission is generally considered to be the main factor driving the HIV epidemic in Africa, recent studies have claimed that iatrogenic transmission should be considered as an important source of HIV infection. In particular, receipt of tetanus toxoid injections during pregnancy has been reported to be associated with HIV infection in Kenya. The objective of this paper is to assess the robustness of this association among women in nationally representative HIV surveys in seven African countries. The association between prophylactic tetanus toxoid injections during pregnancy and HIV infection was analysed, using individual-level data from women who gave birth in the past five years. These data are from the nationally representative Demographic and Health Surveys, which included HIV testing in seven African countries: Burkina Faso 2003 (N = 2424), Cameroon 2004 (N = 2600), Ethiopia 2005 (N = 2886), Ghana 2003 (N = 2560), Kenya 2003 (N = 1617), Lesotho 2004 (N = 1278 ) and Senegal 2005 (N = 2126). Once the odds ratios (OR) were adjusted for five-year age groups and for ethnic, urban and regional indicators, the association between prophylactic tetanus toxoid injections during pregnancy and HIV infection was never statistically significant in any of the seven countries. Only in Cameroon was there an association between previous tetanus toxoid injection and HIV positivity but it became weaker (OR 1.53, 95% CI 0.91 to 2.57) once urban location and ethnic group were adjusted for. Although the risk of HIV infection through unsafe injections and healthcare should not be ignored and should be reduced, it does not seem that there is, at present and in the seven countries studied, strong evidence supporting the claim that unsafe tetanus toxoid injections are a major factor driving the HIV epidemic.

Editors’ note: After simple adjustment for age, location, and ethnicity in these Demographic and Health Survey datasets from seven countries, there were no correlations found between tetanus toxoid injections during pregnancy and HIV infection. Injection safety is important in healthcare settings in Africa, as it is everywhere, but it should not detract from concerted efforts to address the main mode of HIV transmission in these countries – sexual transmission.

Thomson and colleagues aimed to determine the prevalence and types of penile modification and describe the circumstances surrounding this practice among a sample of young methamphetamine users in Thailand. A mixed methods study was conducted in Chiang Mai, Thailand in 2005-6. One hundred young men were surveyed for the quantitative study and in-depth interviews were administered to 9 men, 11 women and 1 transgender. The prevalence of penile modification was 51%, with the most common type being inlaying with muk(s) (61%). The majority of modifications were performed in prison or juvenile detention (80%) by a friend (90%). Motivations for penile modification included peer pressure and perceived enhanced female sexual pleasure. In prison, the practice was veiled in secrecy, the conditions under which modification was performed were unhygienic, sometimes leading to infection, and sharing equipment was common. Men and women reported that condom use was more difficult post modification as condoms were more likely to break or leak and less likely to fit correctly. In addition, sexual intercourse was often painful for the female partner. In conclusion, penile modification is prevalent in this group of young methamphetamine users and is associated with behaviours and consequences that could facilitate the spread of HIV and other sexually transmitted infections.

Editors’ note: Penile modification practices in Thailand date back to the fourteenth century among the aristocracy but today are associated with prisons, the army, and the working class. Over half of one hundred consecutive male participants in a trial to reduce harms associated with methamphetamine use had penile modifications that had been performed in unhygienic settings. The risk of infection, including with blood borne pathogens transmitted through sharing of equipment at the time of the procedure, painful intercourse with trauma experienced by the receptive partner during intercourse, and condom breakage/leakage all raise concerns of increased risk for HIV acquisition and transmission.