Articles in a special issue of the International Journal of STD and AIDS (IJSA), published today, 1 December, point to evidence that blood exposures from unsanitary procedures in healthcare, cosmetic care, and ritual settings account for a substantial share of HIV transmission in Africa. Authors of the articles argue that inadequate science and a lack of political will has led to missed prevention opportunities over many years.

Wallace Dinsmore, a consultant genitourinary physician and IJSA Editor-in-Chief said, "African governments, the WHO, Centers for Disease Control and the UNAIDS have prolonged the epidemic in Africa in a way that could at best be described as utter incompetence. At worst, it smacks of callous politicking. The science has been there all along but some people have chosen to ignore it because it just didn't suit their ends."

Leading epidemiologist, John Potterat, who co-edited this special issue, commented, "Many times in the last seven years, especially in this journal, researchers have presented evidence at odds with the consensus view that penile-vaginal intercourse is driving African HIV epidemics. Governments and international health agencies deliberately chose to ignore that evidence. The path-breaking studies in this issue – several led by African researchers – now show directly that many Africans are at risk from a wide range of common skin puncturing practices that may involve contaminated instruments and materials. By uncritically accepting the orthodox view that HIV is almost exclusively transmitted by sex, public health workers and researchers are complicit in prolonging avoidable suffering."

Professor David Gisselquist, who first triggered the debate regarding non-sexual HIV transmission in Africa in the IJSA seven years ago, reports that double standards (one for rich and one for poor countries) in HIV research ethics, healthcare safety and scientific studies have enabled the HIV pandemic in sub-Saharan Africa. He likens the lack of an ethical framework to the Tuskegee scandal, when US government-funded researchers followed and studied African-American men with syphilis, without treating their infections. Gisselquist argues that important studies in Africa followed HIV-positive men and women, who did not know they were infected, to study HIV transmission to unsuspecting spouses and to children. He comments, "The Tuskegee scandal endured for nearly forty years until journalists brought it to the attention of the non-medical public and there was an outcry. What's urgently needed is a rejection of the shameful racial stereotyping that guides most foreign-funded HIV prevention messages and research in Africa."

The articles in the journal include:

AIDS epidemiology in Africa: a changing of the guard An overview of the articles, highlighting how they emphasise empirical evidence rather than the unsubstantiated belief and default assumptions that have characterised most prior research on HIV transmission in Africa.

Diverse blood exposures associated with incident HIV infection in Calabar, Nigeria In this key scientific study, the authors comprehensively investigated correlates of incident HIV infection in repeat HIV testing clients at Nigerian HIV counselling and testing centres. They examined a broad array of blood and sexual exposures, and found that diverse blood exposures were much more common in clients with new HIV infections. Sexual factors were not associated with new HIV infections. The authors note that their study illustrates how healthcare providers and researchers in Africa and elsewhere can inexpensively identify the factors linked to HIV transmission in their communities.

Horizontally-acquired HIV infection in Kenyan and Swazi children The authors studied HIV infection in children whose mothers were not infected. They found that 3% of Swazi children aged 2 to 12 were HIV infected. One-fifth of the infected children had HIV negative mothers. Analyses suggested that HIV transmission through child sexual abuse could not account for even a small fraction of these children's infections. The authors also compared HIV infected Kenyan children who had uninfected mothers with their HIV negative siblings. The infected children had twice as many types of blood exposure as their uninfected siblings. John Potterat comments: "Imagine if we had found that 2-12 year olds in south London or Brooklyn were infected with HIV when their parents were negative. There would – rightly – be uproar and a call for immediate investigation. But no comprehensive, detailed investigation has ever been conducted in sub-Saharan Africa despite repeated identification of such children over the last 25 years."

Political determinant of variable aetiology resonance: explaining the African AIDS epidemics The author argues that underestimation – or even denial – of transmission of HIV in healthcare has been politically expedient for governments and donor agencies. Allowing individuals and their sexual practices to be blamed for transmission has been more attractive to African policy makers than ensuring safe healthcare and cosmetic care practices. Huntsmann writes: "To be sure, the spread of HIV/AIDS in sub-Saharan Africa (SSA) is unintended. No doubt, African leaders do not want their people to die from AIDS. But to what extent are those currently in power willing to accept fundamental changes in the allocation of political and economic resources in order to effectively address the epidemic's structural drivers? The question seems worth asking and it has been largely ignored in most of the scientific literature and public debate on HIV/AIDS in SSA."

Double standards in research ethics, health-care safety, and scientific rigour allowed Africa's HIV/AIDS epidemic disasters This author argues that double standards (one for rich and one for poor countries) in HIV research ethics, healthcare safety and scientific studies have enabled the HIV pandemic in sub-Saharan Africa. He likens the lack of an ethical framework to the Tuskegee scandal, when US government-funded researchers followed and studied African-American men with syphilis, without treating their infections. In addition, governments have not warned Africans about unsanitary medical, dental, cosmetic, and ritual practices and have not investigated unexplained infections to prevent further transmission. Gisselquist comments "We never wanted to be sitting here seven years later saying 'We told you so'. We wanted our findings to stimulate and assist better scientific and public health responses. Instead, influential health experts and bureaucrats have responded with denial, bad research, and stigmatizing prevention messages that blame Africa's epidemics exclusively on sex."