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
implications have not been accurately described,
especially by critics, and we appreciate this opportunity to set the
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 are 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 2 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 2 and 12, 50 were HIV
infected. 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 with HIV 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 child
sexual abuse, 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
Since the publication of our article, a physician at a
paediatric HIV clinic in Swaziland acknowledged to 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.