Medical professionals practising double standards in research ethics, health-care safety and scientific rigour have allowed HIV epidemics to develop into national disasters in more than a dozen countries in sub-Saharan Africa. Researchers have followed HIV-positive Africans who did not know they were infected to study HIV-related morbidity, mortality and transmission to unsuspecting spouses and children. Public health managers do not warn Africans about risks to contract HIV from unsafe health care, and no African government has investigated any unexplained and suspected nosocomial HIV infection by tracing and testing people who attended suspected clinics. Researchers have avoided finding and talking about nosocomial HIV infections in countries with generalized epidemics. Rejecting double standards in health-care safety and scientific rigour may be essential to solve and stop Africa's HIV epidemic. Allowing competitive international trade in generic drugs to treat AIDS could mitigate some of the harm done by these double standards.

1. Hooper, E. The River. London: Penguin, 2000 Google Scholar
2. Worobey, M, Gemmel, M, Teuwen, DE, Direct evidence of extensive diversity of HIV-1 in Kinshasa by 1960. Nature 2008;455:6614 Google Scholar, Crossref, Medline
3. UNAIDS. 2008 Report on the Global AIDS Epidemic. Geneva: UNAIDS, 2008 Google Scholar
4. Rockwell, DH, Moore, MB. The Tuskegee study of untreated syphilis. Arch Int Med 1964;114:7928 Google Scholar, Crossref, Medline
5. Jones, JJ. Bad Blood: The Tuskegee Syphilis Experiment – A Tragedy of Race and Medicine. New York: The Free Press, 1981 Google Scholar
6. Biraro, S, Morison, LA, Nakiyingi-Miiro, J, Whitworth, JA, Grosskurth, H. The role of vertical transmission and health care-related factors in HIV infection of children: a community study in rural Uganda. J Acquir Immune Defic Syndr 2007;44:2228 Google Scholar, Crossref, Medline
7. Morgan, D, Maude, GH, Malamba, SS, HIV-1 disease progression and AIDS-defining disorders in rural Uganda. Lancet 1997;350:24550 Google Scholar, Crossref, Medline
8. Morgan, D, Malamba, SS, Maude, GH, An HIV-1 natural history cohort and survival times in rural Uganda. AIDS 1997;11:63340 Google Scholar, Crossref, Medline
9. Morgan, D, Malamba, SS, Orem, J, Mayanja, B, Okongo, M, Whitworth, JA. Survival by AIDS defining condition in rural Uganda. Sex Transm Infect 2000;76:1937 Google Scholar, Crossref, Medline
10. Morgan, D, Mahe, C, Mayanja, B, Okongo, JM, Lubega, R, Whitworth, JA. HIV-1 infection in rural Africa: is there a difference in median time to AIDS and survival compared with that in industrialized countries? AIDS 2002;16:597603 Google Scholar, Crossref, Medline
11. Quigley, MA, Hewitt, K, Mayanja, B, The effect of malaria on mortality in a cohort of HIV-infected Ugandan adults. Trop Med Int Health 2005;10:894900 Google Scholar, Crossref, Medline
12. Whitworth, JA, Birao, S, Shafer, LA, HIV incidence and recent injections among adults in rural southwestern Uganda. AIDS 2007;21:10568 Google Scholar, Crossref, Medline
13. Carpenter, LM, Kamali, A, Ruberantwari, A, Malamba, SS, Whitworth, JAG. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999;13:10839 Google Scholar, Crossref, Medline
14. Nakiyingi, J, Whitworth, J, Ruberantwari, A, Child survival in relation to mother's HIV infection and survival: evidence from a Ugandan Cohort Study. AIDS 2003;17:182734 Google Scholar, Crossref, Medline
15. Mulder, DW, Nunn, A, Kamali, A, Kengeya-Kayondo, JF. Post-natal incidence of HIV-1 infection among children in a rural Ugandan population: no evidence for transmission other than mother to child. Trop Med Int Health 1996;1:815 Google Scholar, Crossref, Medline
16. Ross, A, Van der Paal, L, Lubega, R, Mayanja, BN, Shafer, LA, Whitworth, J. HIV-1 disease progression and fertility: the incidence of recognized pregnancy and pregnancy outcome in Uganda. AIDS 2004;18:799804 Google Scholar, Crossref, Medline
17. Hugonnet, S, Mosha, F, Todd, J, Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr 2002;30:7380 Google Scholar, Crossref, Medline
18. Senkoro, KP, Boerma, JT, Klokke, AH, HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991 through 1996. J Acquir Immune Defic Syndr 2000;23:194202 Google Scholar, Crossref, Medline
19. Zaba, B, Whitworth, J, Marston, M, HIV and mortality of mothers and children: evidence from cohort studies in Uganda, Tanzania, and Malawi. Epidemiology 2005;16:27580 Google Scholar, Crossref, Medline
20. Public Health Service (PHS). Policy on Informing Those Tested about HIV Serostatus. Washington, DC: PHS, 1988. Available at: http://www.hhs.gov/ohrp/humansubjects/guidance/hsdc88jun.htm (last accessed 9 September 2007) Google Scholar
21. Allen, SA, Karita, E, N'gandu, N, Tichacek, A. The evolution of voluntary testing and counseling as an HIV prevention strategy. In: Gibney, L, DiClemente, RJ, Vermund, SH, eds. Preventing HIV in Developing Countries: Biomedical and Behavioral Approaches. New York: Kluwer Academic, 1999:87108 Google Scholar
22. Quinn, TC, Wawer, MJ, Sewankambo, N, Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000;342:9219 Google Scholar, Crossref, Medline
23. Gray, RH, Wawer, MJ, Brookmeyer, R, Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda. Lancet 2001;357:114953 Google Scholar, Crossref, Medline
24. Humphrey, JH, Iliff, PJ, Marinda, ET, Effects of a single large dose of vitamin A, given during the postpartum period to HIV-positive women and their infants, on child HIV infection, HIV-free survival, and mortality. J Infect Dis 2006;193:86071 Google Scholar, Crossref, Medline
25. Piwoz, EG, Iliff, PJ, Tavengwa, N, An education and counseling program for preventing breast-feeding-associated HIV transmission in Zimbabwe: design and impact on maternal knowledge and behavior. J Nutr 2005;135:9505 Google Scholar, Medline
26. WHO. AIDS and HIV Infection: Information for United Nations Employees and Their Families. Geneva: WHO, 1991. Doc. no. WHO/GPA/DIR/91.9 Google Scholar
27. UNAIDS. AIDS and HIV Infection: Information for United Nations Employees and Their Families. Geneva: UNAIDS, 1999 Google Scholar
28. UNAIDS. Living in a World with HIV and AIDS: Information for Employees of the UN System and Their Families. Geneva: WHO, 2004 Google Scholar
29. WHO. Report of the First Meeting of the Steering Committee on Immunization Safety. Geneva, 25–26 October 1999. Doc. no.: WHO/V&B/00.17. Geneva: WHO, 2000 Google Scholar
30. ORC Macro. Ghana Service Provision Assessment Survey 2002. Calverton, MD: ORC Macro, 2003 Google Scholar
31. ORC Macro. Kenya Service Provision Assessment Survey 2004: Maternal and Child Health, Family Planning and STIs. Calverton, MD: ORC Macro, 2005 Google Scholar
32. ORC Macro. Kenya HIV/AIDS Service Provision Assessment Survey 2004. Calverton, MD: ORC Macro, 2005 Google Scholar
33. ORC Macro. Rwanda Service Provision Assessment Survey 2001. Calverton, MD: ORC Macro, 2003 Google Scholar
34. ORC Macro. Rwanda Service Provision Assessment Survey 2007. Calverton, MD: ORC Marco, 2008 Google Scholar
35. ORC Macro. Tanzania Service Provision Assessment Survey 2006. Calverton, MD: ORC Marco, 2007 Google Scholar
36. ORC Macro. Uganda Service Provision Assessment Survey 2007. Calverton, MD: ORC Marco, 2008 Google Scholar
37. ORC Macro. Zambia HIV/AIDS Service Provision Assessment Survey 2005. Calverton, MD: ORC Macro, 2006 Google Scholar
38. Berkley, S, Weeks, M, Barenzi, J. Immunization and fear of AIDS [letter]. Lancet 1990;335:478 Google Scholar, Crossref, Medline
39. Mann, JM, Francis, H, Davachi, F, Risk factors for human immunodeficiency virus seropositivity among children 1–24 months old in Kinshasa, Zaire. Lancet 1986;ii:6547 Google Scholar, Crossref
40. Lepage, P, Van de Perre, P, Carael, M, Butzler, JP. Are medical injections a risk factor for HIV in children? Lancet 1986;ii:11034 Google Scholar, Crossref
41. Pokrovskii, VV, Eramova, II, Deulina, MO, An intrahospital outbreak of HIV infection in Elista [in Russian]. Zh Microbiol Epidemiol Immunobiol 1990;4:1723 Google Scholar
42. Pokrovsky, VV. Localization of Nosocomial Outbreak of HIV Infection in Southern Russia in 1988–89. Eighth International Conference on AIDS, Amsterdam, 19–24 July 1992. Abstract no. PoC 4138 Google Scholar
43. Drucker, E, Apetrei, C, Heimer, R, Marx, P. The role of unsterile injections in the HIV pandemic. In: Volberding, PY, Sande, MA, Lange, J, Green, WC, Gallant, JE, eds. Global HIV/AIDS Medicine. Philadelphia: Saunders, 2008:75567 Google Scholar, Crossref
44. Visco-Comandini, U, Cappiello, G, Liuzzi, G, Monophyletic HIV type 1 CRF02-AG in a nosocomial outbreak in Benghazi, Libya. AIDS Res Hum Retroviruses 2002;18:72732 Google Scholar, Crossref, Medline
45. In the courts: Health workers sentenced to prison in Kazakhstan for criminal negligence after HIV outbreak among women, children. Kaisernetwork.org, 2 January 2008. Available at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=49564 (last accessed 27 March 2009) Google Scholar
46. Hitimana, D, Luo-Mutti, C, Madraa, B, A Multicentre Matched Case Control Study of Possible Nosocomial HIV-1 Transmission in Infants and Children in Developing Countries. Ninth International Conference on AIDS, Berlin, 6–11 June 1993. Abstract no. WS-C13-2 Google Scholar
47. Global Programme on AIDS. 1992–1993 Progress Report, Global Programme on AIDS. Geneva: WHO, 1993 Google Scholar
48. Bailey, RC, Moses, S, Parker, CB, Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369: 64356 Google Scholar, Crossref, Medline
49. Watson-Jones, D, Weiss, HA, Rusizoka, M, (2008) Effect of herpes simplex suppression on incidence of HIV among women in Tanzania. N Engl J Med 2008;358:156071 Google Scholar, Crossref, Medline
50. Auerbach, DM, Darrow, WW, Jaffe, HW, Curran, JW. Cluster of cases of the acquired immune deficiency syndrome: patients linked by sexual contact. Am J Med 1984;76:48792 Google Scholar, Crossref, Medline
51. Gisselquist, D, Potterat, JJ, Brody, S. HIV transmission during pediatric health care in sub-Saharan Africa: risks and evidence. S Afr Med J 2004;94:10916 Google Scholar, Medline
52. N'Galy, B, Ryder, RW, Bila, K, Human immunodeficiency virus infection among employees in an African hospital. N Engl J Med 1988;319:11237 Google Scholar, Crossref, Medline
53. Randerson, J. WHO accused of huge HIV blunder. New Scientist 6 December 2003;180:89 Google Scholar
54. Viswanathan, M, Lux, L, Kirmeyer, S, Madhava, V, Lohr, K, Cohen, M, Swinson, T. Examination of Health Care Transmission of HIV/AIDS in Sub-Saharan Africa and the Caribbean Region: A Literature Review, Expert Panel, and Report. Final Report. RTI Project Number: 08490.005. Raleigh: Research Triangle Institute, 2004 Google Scholar
55. Schmid, GP, Buve, A, Mugyenyi, P, Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections. Lancet 2004;363:4828 Google Scholar, Crossref, Medline
56. Gisselquist, D, Potterat, JJ. Request for disclosure of available data associating HIV with medical injections. SIGNPOST, Post 00269, 5 January 2005. Available at: http://uqconnect.net/signfiles/Archives/ (last accessed 1 May 2009) Google Scholar
57. Todd, J, Grosskurth, H, Changalucha, J, Risk factors influencing HIV infection incidence in a rural African population: a nested case-control study. J Infect Dis 2006;193:45866 Google Scholar, Crossref, Medline
58. Gisselquist, D. Points to Consider: Responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis & Abbey, 2008 Google Scholar
59. Mermin, J, Musinguzi, J, Opio, A, Risk factors for recent HIV infection in Uganda. JAMA 2008;300:5409 Google Scholar, Crossref, Medline
60. Kumwenda, JJ, Makanani, B, Taulo, F, Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi. Clin Infect Dis 2008;46:191320 Google Scholar, Crossref, Medline
61. Mishra, V, Medley, A, Hong, R, Gu, Y, Robey, B. Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. DHS Comparative Reports No. 22. Calverton, MD: Macro International Inc., 2009 Google Scholar
62. Lopman, BA, Garnett, GP, Mason, PR, Individual level injection history: A lack of association with HIV incidence in rural Zimbabwe. PLoS Med 2005;2:e37 Google Scholar, Crossref, Medline
63. Gray, RH, Li, X, Kigozi, G, Increased risk of incident HIV during pregnancy in Rakai, Uganda: a prospective study. Lancet 2005;366:11828 Google Scholar, Crossref, Medline
64. Garnett, GP, Fraser, C. Let it be sexual – Selection, aggregation and distortion used to construct a case against sexual transmission [letter]. Int J STD AIDS 2003;14:7824 Google Scholar, Link
65. Gray, R, Thoma, M, Kiwanuka, N, Wawer, M, Serwadda, D. HIV transmission through health care in sub-Saharan Africa, authors' replies [letter]. Lancet 2004;364:1666 Google Scholar, Crossref, Medline
66. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 1999;11:40 Google Scholar

Vol 20, Issue 12, 2009