Brewer, D., Okinyi, M., & Potterat, J. (2009). The facts about HIV infected Swazi children. Times of Swaziland, December 16, http://www.times.co.sz/index.php?news=12942.

Sir,

During the last two weeks, there has been much discussion in the Swazi press about the research we conducted on HIV transmission in Swazi and Kenyan children.  Our work and its implications have not been accurately described, especially by critics, and we appreciate this opportunity to set the record straight.  

We did not specifically accuse Swazi nurses or hospitals of accidentally spreading HIV to children.  The Daily Telegraph (UK) was the first newspaper to report on our work.  The Telegraph reporters never contacted us and they misreported several aspects of our research.  The coverage in the Swazi press appears to be based on the inaccurate Daily Telegraph story.

In our study of the Swazi children, we analysed data from the Swaziland 2006-07 Demographic and Health Survey (DHS).  This survey was carried out by the Swaziland Central Statistical Office.  The survey was funded by USAID, several United Nations organisations, and other domestic, foreign, and non-governmental agencies.  The DHS data is publicly available to researchers throughout the world for further analysis of factors related to health in Swaziland.

The Swaziland DHS selected respondents in such a way that the survey results are representative of the nation as a whole.  The survey involved testing persons aged two to 49 years for HIV infection.  Mothers were interviewed about all children living in their households and asked to indicate which were their offspring by birth.  In our analysis, we included only those children who lived with their biological mothers.  

Of such children, between the ages of two and 12, 50 were infected with HIV.  Eleven of these children had mothers who were HIV negative; the youngest of these 11 was two years old and the oldest was 12 years old.  From these results and population figures for the nation, we estimated that approximately 1 800 Swazi children are infected but have uninfected mothers.  

The Swaziland DHS did not include information on factors that might be related to children getting infected with HIV.  However, using information from a published UNICEF survey of Swazi youth about sexual abuse of children, we showed that such abuse could not account for more than a very small fraction of children’s HIV infections. 

We also studied HIV infected Kenyan children who had HIV negative mothers. We compared these children to their uninfected siblings.  The infected children were much more likely to have had skin punctures in formal and informal healthcare.  No other study of HIV infected children with HIV negative mothers in sub-Saharan Africa has been as detailed or comprehensive as our Kenyan study.  

The results from the Kenyan study and the age of the infected Swazi children strongly imply that the HIV infected Swazi children with uninfected mothers became infected through unhygienic skin puncturing exposures. Scientific and media reports in recent years also indicate that formal and informal healthcare in Swaziland is not reliably safe.  With the available information, it is impossible to know precisely when, where, and how the children became infected, although clearly they were infected sometime between 1994 and 2005. 

Since the publication of our article, a physician at a pediatric HIV clinic in Swaziland informed us that infected children with uninfected mothers continue to be found. For over 25 years, HIV infected children with uninfected mothers have been repeatedly reported by doctors and researchers throughout sub-Saharan Africa, including South Africa in 2009. 

An ethical and scientific response to our results would be to investigate the possibility of blood-borne HIV transmission in both children and adults in Swaziland as well as elsewhere in sub-Saharan Africa.  This is precisely what we called for in our article and is also what Senator Prince Kusa Dlamini has recently demanded. To instill both public and scientific confidence, these investigations must be rigorous, comprehensive, transparent, and independent of individuals and organisations that have denied the potential importance of blood-borne HIV transmission in Africa.  Investigations should also be designed to identify problems and correct them, and not to assign blame or prosecute. 

It is not sufficient to claim that healthcare is mostly safe.  Healthcare providers must demonstrate that healthcare is always safe, patients must insist that it is so, and governments must ensure that it is.  In the meantime, the public must be educated about the full spectrum of risks of blood-borne HIV transmission and how to avoid them.