The World Health Organization's long-held position that dirty needles cause 2.5 percent of African HIV exposures is too conservative, says a leading researcher at the U.N. agency, prompting questions about a congressional bill focused mainly on unsafe sex.
Health and Human Services Secretary Tommy Thompson has launched a review of all research linking AIDS and medical injections, possibly laying the groundwork for changes in how the legislation's $15 billion in funding is distributed.
Sen. Jeff Sessions of Alabama, a member of the Senate's health panel, requested the review after he turned up a WHO report listing four separate studies that find dirty needles responsible for 8, 15, 41 and 45 percent of exposures in sub-Saharan Africa.
The report, dated Dec. 19, 2002, concludes that "the lowest attributable fraction calculated on the basis of the data provided by the authors (8 percent) exceeds our 2.5 percent modeled attributable fraction, suggesting that our estimate is conservative."
Yvan Hutin, a WHO researcher who wrote the report, acknowledged the 2.5 percent number was probably low, although just how low remains a point of debate. Regardless, he said, it would be wise to consider an education campaign on unsafe needles, perceived by many as an easier and cheaper problem to correct than unsafe sex.
"It remains a very good investment to do injection safety," said Hutin, reached at WHO headquarters in Geneva. "It doesn't matter whether it's 2.5 percent or more or less."
Sessions, however, contends it would have mattered while Congress was balancing the spending priorities in the AIDS bill, which President George W. Bush signed last month. If the widely recognized figure was even a little higher, he said, Congress would have poured far more money into needle education — and possibly even a clean-needle exchange program.
But some at WHO say cost isn't the only issue. Because it is widely believed that sex is more responsible for AIDS than needles, they contend the message would be diluted if needle and sex education were given equal weight.
"We'd all like to see there be no unsafe injections," said George Schmid of WHO's Department of HIV/AIDS. "But to begin to place a large emphasis on the unsafe injections, which likely would be at the expense of resources devoted to unsafe sex, would be an unwise decision. We need to keep the resources where the problem is."
That position outrages Sessions, who suspects it's the reason WHO continues to tout an estimate its researchers acknowledge is low.
"This is hogwash," he said. "It's about numbers. It's about infections. You can certainly carry two messages. This is a life-and-death issue. Whatever bureaucratic objections are occurring here have got to be overcome because people are dying every day."
A major part of the AIDS bill could be rerouted if new research about injections surfaces, Sessions said. But HHS officials aren't saying how likely that is, or even when the study is expected to be finished.
"Like Sen. Sessions, we too are interested and concerned with how AIDS is actually transmitted," said HHS spokesman Bill Pierce.
Sessions' interest in the connection between AIDS and injections was heightened in March after he invited Dr. David Gisselquist to testify to the Senate. After reviewing some 19 years of research, Gisselquist concluded that at least one-third of AIDS exposures in sub-Saharan Africa are due to contaminated needles in medical treatment.
Gisselquist contends that because WHO's focus has been on unsafe sex for so long, it's deliberately overlooking good research like his. But although Hutin now doubts the 2.5 percent number, he says Gisselquist's estimate is inflated.
"If WHO says we should put more emphasis on health care risks, people will say, 'Why didn't you do it the last 15 years?"' Gisselquist said.
Similar concerns are raised by Gary Cohen, president of BD Medical Systems, a New Jersey-based company that makes disposable syringes that permanently lock after they're used once. The syringes cost about 6 cents each, he said.
For $75 million to $100 million a year, Cohen said, all of Africa could be supplied with the safe syringes. He contends that a needle distribution program is the most effective way to combat the problem because many people in Africa don't have the option to demand clean needles.
By Jeffrey McMurray