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

Stephen F. Minkin


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.


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 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 overburdened clinics and hospitals without sufficient

resources to ensure sterile procedures and safe blood.


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.


AIDS in the United States if we had ignored the potential for hospitals and

clinics to become centers of HIV infection. Suppose we highlighted 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 US and Africa would look more similar. The US would

have an overwhelming health problem, with large numbers of women and children

dying from AIDS.


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 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



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 childbirth earlier and

have more children than Americans. They need more life-saving transfusions for

childbirth complications and for pregnancy-related 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.


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.


following comments by Charles Obonyo, a Kenyan physician, highlight a reality

ignored by experts and the media covering AIDS:


has become clear in recent years that the prevalence of severe pediatric anemia

requiring blood transfusion, particularly in malaria-endemic regions has

markedly increased. At the same time, the prevalence of HIV among blood donors

is also on the increase, to the extent that safe blood has become a scarce and

rare commodity."


the US 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 were unsafe in

African countries for which data was available.


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



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 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.


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 US, the

leading global source for AIDS prevention funds, has so far paid scant attention

to the problem. As the major donor, the US 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

and effective.



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 Brattleboro, Vermont. The

NIP web site address is www. Please e-mail comments to [email protected]

or write to P.O. Box 6073, Brattleboro, VT 05302

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