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Blood Exposures Ignored in Racial Disparities in HIV Prevalence

Dear Editor We commend Kaul and colleagues for exploring factors other than sex to explain the highly disproportionate burden of human immunodeficiency infection (HIV) in black communities worldwide. They appeal for reassessment of the traditional monoarticular epidemiologic paradigm – a narrow focus on sex – and encourage redirecting investigative energies into the biological arena, with emphasis on viral factors (e.g., viral load, clade-specific infectivity), host genetic factors (e.g., mucosal and immunologic susceptibility), and endemic co-infections (e.g., tropical and ⁄ or sexually transmitted infections). While it is plausible that biological factors are related to enhanced HIV transmission, Kaul and colleagues, surprisingly, overlook very efficient blood-borne transmission. There is ample and growing evidence that blood exposures in unhygienic medical and dental care, cosmetic care, and rituals are linked to HIV transmission throughout sub-Saharan Africa. Such exposures may even play a role in blacks’ elevated HIV prevalence in America. We agree with Kaul and colleagues’ final conclusion that ‘To develop better prevention tools, it is critical that communities, researchers and policy makers come together to discuss and investigate these tremendous disparities in an open and non-judgmental fashion’. Indeed, open mindedness should impel rigorous investigations for determining modes of HIV transmission that include comprehensive assessment of blood and specific sexual exposures.