Africa HIV: Perverts or Bad Med?

Why is AIDS so much more common in Africa than elsewhere?  The standard theory is, essentially: Africans are sex perverts.  Details have varied over the years: too much prostitution or polygamy or anal sex, too many partners, not enough condoms or circumcision, or girls starting too young.  Most of these theories haven’t found much support, or (like circumcision) are too weak to explain African excess.  (For example, polygamy reduces risk.)

The currently popular version is that Africans have too many concurrent (at the same time) long-term partners.  There is some evidence that this happens in African more than elsewhere, and there are theoretical reasons to expect it to speed sex epidemics.  But a December review says the case is far from closed.  From Lancet in October:

A four-city African study actually found lower rates of concurrency in places with larger HIV epidemics, and a study using nationally representative surveys in 22 countries (all but one of which was in Africa) concluded that ‘‘the prevalence of concurrency does not seem correlated with HIV prevalence at the community level or at the country level, neither among women nor among men.’’ Additionally, Wellings and colleagues reviewed global sexual behaviour and could not find sufficient data to assess whether rates of concurrency differ across the world.

The main reply is:

[Critics] offer no credible alternative explanation … It is simply not plausible that serial monogamy by itself could generate the explosive generalised epidemics.

But Karl Smith and David Friedman suggest bad med instead:

Much of the transmission may be due to sloppy medical procedures, in particular the reuse of needles for injections.

In fact, there is a whole journal devoted to this thesis:

Seven years ago the International Journal of STD & AIDS (IJSA) began actively encouraging reexamination of the prevailing view that penile–vaginal sex was driving African HIV epidemics, … Although the IJSA-published dissenting views have largely been ignored, dismissed or fiercely resisted by established HIV researchers and allied health agencies.

A 2007 Annals of Epidemiology paper found:

In regression analyses, nonuse of disable syringes is associated robustly with greater HIV prevalence in all models. … Greater HIV prevalence also is associated with higher Gini Index, less female economic activity, less urbanization, and less percentage of Muslims.

World-wide, resusable needles are the second biggest binary predictor of HIV (after Sub-Saharan African location and before gender-literacy ratio):


Focusing on Sub-Saharan Africa, resusable needles are a huge predictor, as is a U-shaped dependence on Tetanus coverage:


For balance, see a brief critique of this view:

If injections were a major source of transmission, one would expect high rates during childhood, when children receive most preventive vaccinations and many health care visits. Yet a study of mother-child dyads in public health facilities in South Africa found only 1.4% of HIV-positive children aged 2–9 years had HIV-negative mothers. While this study needs to be replicated in other settings, it does not indicate that injections play a major role in transmission among children.  Further, if transmission were primarily due to medical injections, one would expect similar rates of HIV infection among males and females. However, there was a five-fold difference in our dataset (10.6% of adolescent females vs. 2.1% of adolescent males were HIV-positive). Potterat et al present data suggesting teenaged females were more likely to have received recent injections, but their argument is flawed in several ways. … Although antibiotic injections are often used to treat sexually transmitted infections (STI) such as syphilis, in our survey, more male than female adolescents ever sought treatment for an STI from a health worker (48% vs. 29%, respectively).

I’m not saying I’m sure bad docs are a big cause of African AIDS, but the possibility sure seems to deserve more attention than it has been getting.  More related papers here, here, here, here, here, here, here, and here.

Added 10a: For you skeptics, yes African data on cause of death is suspect, but overall death rates are much less so, and Africa has clearly suffered a huge death increase relative to pre-AIDS trends.

Added 14Feb: We often think of anti-racism as core to our culture, but when our choice is to think of blacks as sex perverts or to think of med as deadly, we clearly choose the former over the later.  This suggests heroic med is far more central to our culture than anti-racism.

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  • I have been very puzzled about africa especially after reading the following AIDS transmission probabilities from wikipedia.

    The main statistic of interest is that the probability of transmission of an HIV infection in unprotected vaginal intercourse is about 1 in 1500. In contrast the probability of a pregnancy with unprotected intercourse is probably about 1/30 when the woman is not already pregnant and is in her prime. This would imply that the rate of birth of babies without HIV should far outstrip the rate of people getting infected with HIV… which implies of course that you can never have a sizeable percentage of the population infected with HIV…
    The following will of course change the equation…
    1. Unprotected sex followed with contraceptive pill/morning after pill or an abortion in the event of pregnancy. This will increase the number of HIV infected people but not children.
    2. Unprotected sex with women who are already pregnant.
    3. Unprotected sex with pre-pubescent of post menopausal women.

    It doesn’t appear to me that 1,2 and 3 is enough to bridge the difference between 1/30 and 1/1500.

    That in turn would imply that unprotected heterosexual intercourse can’t be the dominant reason for the double digit percentage of HIV cases in Africa, which is in line with this post. Thoughts?

  • Michael Turner

    “Why is AIDS so much more common in Africa than elsewhere?”

    You mean, why is AIDS *reported* to be so much more common in Africa?

    Ever notice that a lot of AIDS African aid money goes into the same pot with malaria and TB? Both malaria and TB are much bigger killers than AIDS. Did we notice they were big killers before AIDS hit the headlines? Not so much. AIDS was a disease first noticed in the developed world, and in association with SEX (oh did that get your attention?)

    The (to me, very plausible) theory that unprofessional use of hypodermics has spread the condition widely in Africa has been around for over two decades. However, it isn’t carefully scrutinized or much investigated. Why not? Well, as with anything: cui bono?

    AIDS has been a rainmaker for public health aid generally, in Africa. Sure, on the face of it, it sounds like a conspiracy theory: overstating the epidemic and understating certain embarrassing factors could be rife, where it brings in more aid money. But look, this is AFRICA we’re talking about here: an entire continent of corrupt governments, which is just another way to say government by co-conspirators. That means that even public health professional there will do whatever it takes to keep money coming in — perhaps especially those among them who want to do the most good.

    The sad thing is that some people are probably Acquiring an Immune Deficiency Syndrome just from being jabbed with contaminated needles, and perhaps dying of opportunistic infections without even being infected with HIV. After all, if you were a pathogen, what better opportunity to infect that to be drawn directly from one host and injected into another mere minutes later? And after enough of that, a patient’s immune system is likely to be overwhelmed.

  • Stuart Armstrong

    Thanks for posting this, I had no idea this was a serious alternative explanation!

  • TheQuickBrownFox

    Part of the reason is a very fuzzy definition of HIV/AIDS and a fuzzy testing procedure. General poor health and weak immune systems are interpreted as AIDS and therefore HIV is assumed. In actual fact, the link between the two is not quite as concrete as generally perceived and AIDS prevelance patterns aren’t consistent with that of an infectious disease.

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  • Curt Adams

    Outside of Africa we don’t see AIDS epidemics driven by heterosexual transmission. HIV spreads either in IV drug abusers or male homosexuals; those individuals then spread it via heterosexual activity. There’s a strong combination effect too; if, say a typical heterosexual IV drug abuser had a 80% of spreading HIV via sharing needles before death and an 80% chance of spreading via heterosexual contact there’s no epidemic if only one route is operational; but if both are then you have an epidemic.

    I can think of one strong piece of evidence that in Africa heterosexual transmission is very important; when Uganda went to an abstinence-only sex education policy (at the behest of the Bush administration) infection rates tripled. In combination with the heavily female-biased incidence in Africa that implicates heterosexual transmission as the source of most cases there.

    There’s a big problem with looking at concurrency rates: you expect concurrency rates to drop in the presence of an HIV epidemic. You could actually see a negative correlation even if concurrency was the primary cause.

    Viljay: The numbers I’ve seen on estimates of heterosexual transmission are much higher, on the order of 1 in a 100. The numbers you cite are from the US, where the infection rates are probably greatly reduced from HIV treatment and from treatment of other STDs (HIV spreads more easily in people with other STDs).

    • Regarding Uganda, I had always heard their ABC program was very successful. I don’t see anything in Wikipedia about a change during the Bush admin.

    • Michael Turner

      “Uganda went to an abstinence-only sex education policy (at the behest of the Bush administration) infection rates tripled.”

      *Tripled*? I’m no fan of Bush or what his administration was pushing in Uganda, but *tripled*?

      From a story in the Guardian (no fan of the Bush administration):

      “Uganda has successful brought down prevalence rates from a high of more than 20% in the 1980s to around 6% in 2000. In recent years there has been a small increase.”

      A tripling of infection rates should result in something higher than “a small increase” in overall prevalance, over a period of a decade, even with some damping because of higher mortality rates.

      I’d ask for reliable statistics about this, but I know better.

    • ECM

      Uh, as others have said: there was no tripling of AIDS in Uganda due to abstinence-only–where did you ever get this idea??

  • Jody

    I’m with the one jumping over the lazy dog in that I’ve repeatedly heard that an AIDS diagnosis is given very liberally in Africa.

  • Joshua Miller

    This is an interesting post. Very interesting, even. Why do you negate your good work with such dishonestly juvenile signalling in the title? It suggests that you know this is good work and want us to know that you don’t care if your good work is taken seriously. But surely it’s more valuable to you and to your readers to honestly signal good work than to project inadequacies where none exist.

  • If bad med is very bad, then having good med (defined as med that avoids bad med mistakes) is a very good thing.

  • Michael, Quick, and Jody, see my added to the post.

    Curt, what else happened at the same time as abstinence-only sex education policy in Uganda? What is the data supporting the 1% transmission rate estimate?

    Peter, the mafia offers the same sort of protection value.

  • Russ Andersson

    My unconfirmed view of this is that the role of migrant workers in african societies is unusually high relative to elsewhere, so the spread of aids is more a function of having high proportions of migrant workers than any culteral or behavioral differences.

    Most notably in South Africa, many young men leave their villages and go and work on the mines. Mining is a huge employer and major part of the economy, and these poor folks contract aids while living in mining hostels away from home. Aids prevalentcy in mine workers is around one in three. which is high, but it also means that every year millions of young men return home taking aids with them and spreading the disease.

    The net result is that African societies have a system that links high pockets of aids incidences, with a mechanism for transmitting it to other segments of society.

  • TheQuickBrownFox


    What else could have happened at the same time to increase death rates other than HIV/AIDS, which could have existed in smaller quantities long before it was discovered?

    Could reported AIDS be linked more to poor general health due to poverty than anything else? This question needs to be answered without conflating “poverty” with “being economically poor”, since it has been long possible to live a healthy, happy life without money in the right circumstances. A drug-abusing, fast-food eating, STD-suffering American who earns a decent wage can be much more susceptible to immune system problems than the average member of a tribal society with good access to natural resources.

  • Singularity7337

    LOL, Anals of epidemiology.

  • Obviously it has something to do with the fact that Africa has a lot of black people. Why else would you see high rates of AIDS in Detroit and Port-au-Prince?

    I would guess that

    (1) there was some epidemic which swept the world in the past but did not hit sub-Saharan Africa. The same genes which helped people to survive that epidemic provide some protection against AIDS.

    (2) being less intelligent than other folks (generally speaking and on average), blacks are a lot more likely to engage in risky sex practices.

  • Completely off-topic: Mencius Moldbug has linked to a video of your debate, so folks don’t have to settle for just audio now. He also seems willing to shift to inductive evidence. At least, I think so, I’ve only read the very beginning.

    brazil84, I believe the AIDS rate among African-Americans is much lower than in sub-saharan Africa as a whole. I agree on the epidemic issue though, it is believed that the Black Death is responsible for lower vulnerability in Europe.

    • “brazil84, I believe the AIDS rate among African-Americans is much lower than in sub-saharan Africa as a whole.”

      But much higher than non-black Americans, right?

      • Christic

        According the CDC, HIV is more prevelant among white homosexual males.

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  • Douglas Knight

    Yes, the time series on deaths suggests that AIDS is endemic in Africa, but the correlations you quote are not based on death rates, but on HIV diagnoses, which are not reliable in Africa.

    Robert May claims that he and Anderson made predictions based on concurrency in the mid 80s and were roughly correct. That’s not a lot bits of information, but prospective studies are vital in politically charged fields where you don’t trust the researchers.

    • The key quote from that article:

      The World Health Organization and the Population Council in New York produced models that were much more complex, including very detailed demographic data, of but where HIV transmission probability of was treated as if for measles, compounding independently randomly for each individual sex act. Thus, in effect, their an models assumed that, knowing nothing of the infective status of individuals, 1 sex act with each of 10 different sex workers was effectively equivalent to 10 acts with 1; our data-governed, but otherwise much simpler, model saw the former as roughly 10 times more risky. So it was not surprising that the later models, apparently “more realistic” by virtue of their computational complexity, suggested a less gloomy view than ours. Sadly, but understandably, our predictions have proved more reliable.

      These are not predictions based on concurrency, the same partners over and over, but simply on the number of partners each person has.

  • Nanonymous

    Any explanation that explains Africa should also be able to explain the USA. CDC data for 2007:

    Estimated cumulative number of HIV cases for Blacks – 426,003 ; for Whites – 404,465; for Hispanic of any race – 169,138. Let say that respective percentages in population are 12, 65 and 15% of total. Means that the rate for Blacks is 5.7 and 3.1 times higher than for Whites and Hispanic, respectively. 3X is a big number to explain by SES alone.

    Same trend with gonorrhea:

    Black rate is 20.7X that of Whites and 9.8X of Hispanic. Gonorrhea ihas nothing to do with reuse of syringes.

  • The use of the word “perverts” in your summation of the so called standard theory is poor form for someone who authors a blog on overcoming bias.

    A much higher than normal incidence rate of STDs is positively correlated to a lack of self-control.

    That this makes people go intellectually soft for fear of some Orwellian blowback doesn’t change some very basic facts.

  • The dangers of reused needles spreading AIDS were well recognized at least by 1983. For example, in 1989 Boris Yeltsin bought $100,000 worth of disposable hypodermic needles in America to distribute in Russia to fight the spread of AIDS.

    Surely, some moderately affluent African country like Botswana has been able at some point since the 1980s to use needles that were new or thoroughly disinfected in bleach. What has the effect been there?

    • In America, needle distribution is strongly resisted by conservatives; and African countries are more conservative than America. So I wouldn’t be surprised if that had never happened.

  • I just added to this post.

    Steve, the whole point of the data analysis shown above was that nations varied in their use of disposable needles, allowing us to see that HIV anti-correlates with such use.

  • AIDS is a goldmine of bias in reporting. Sorry that I’m not going to dig up the references for these; it would take a long time.

    – There is evidence that susceptibility to AIDS has a strong genetic component.

    – One such piece of evidence is the fact that the probability of catching AIDS from a sex partner is (according to 2 studies that I read about 20 years ago using married couples where one partner had AIDS) independent of the number of times you have sex with them. If you’re going to catch AIDS, you’re going to catch it; if you’re resistant, you won’t.

    – Another piece of evidence, discovered recently, is a particular gene variant that causes susceptibility to AIDS. I’ve seen this referred to in one paper but could not find the original source. You’d think this would have been trumpeted on the front page of every newspaper, but no. I don’t know if this variant is more common in Africa.

    – Originally, the different spread of AIDS in Africa was explained by saying that they had a different variety of AIDS there. But as now many people from Africa have brought that variety to America, and it has failed to spread in black communities in America except where there is heavy drug use, it’s clear that there is some environmental factor protecting us in America. I’ve been saying for nearly 20 years now that AIDS research should focus on looking for this protective factor. A few years ago, someone found that infection with malaria is strongly correlated with infection with AIDS. IIRC there’s other evidence that malarial infection reduces resistance to AIDS. We had a scientist here from Cameroon last year, Marceline Ngounoue, looking into this; but I don’t know if she had any results.

  • dlr

    Oh come on, look at all the places where AID’s infection rates are highest. Most are tropical countries, like Thailand, the Caribbean, Africa, Brazil etc. Time to look at the effects of heat and humidity in transmission rates.

  • Patrick

    These persons dont actually have AIDS, they are simply diagnosed as having AIDS

  • Patrick

    Here is the pressing question for me:

    “Why is the mortality of
    HIV-antibody-positives treated with anti-HIV drugs 7–9%, but that of all (mostly untreated) HIV-positives
    globally is only 1×4%?”

    That comes from an article by Duesberg et. al. at

  • Conventional view, spelled out:

    “A minority of scientists claim that as many as 40% of HIV infections in African adults may be caused by unsafe medical practices rather than by sexual activity. The World Health Organization states that about 2.5% of AIDS infections in sub-Saharan Africa are caused by unsafe medical injection practices and the “overwhelming majority” by unprotected sex.”

    Alternative hypothesis for “African AIDS” phenomenon:

    “HIV spreads readily through heterosexual sex in Africa, but less so elsewhere. One possibility being researched is that schistosomiasis, which affects up to 50% of women in parts of Africa, damages the lining of the vagina.”

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