DHS COMPARATIVE 

REPORTS 21

MEDICAL INJECTION USE AND HIV 

IN SUB-SAHARAN AFRICA

OCTOBER 2008

This publication was produced for review by the United States Agency for International Development (USAID). It was prepared by 

Vinod Mishra and Shane Khan of Macro International Inc., Li Liu of Johns Hopkins University, and Benny Kottiri of USAID.
MEASURE DHS assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about the MEASURE DHS project can 

be obtained by contacting Macro International Inc., Demographic and Health Research Division, 11785 

Beltsville Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: 

reports@macrointernational.com; internet: www.measuredhs.com). 

The main objectives of the MEASURE DHS project are: 

to provide decisionmakers in survey countries with information useful for informed policy 

choices; 

to expand the international population and health database; 

to advance survey methodology; and 

to develop in participating countries the skills and resources necessary to conduct high-quality 

demographic and health surveys. 
DHS Comparative Reports No. 21 

Medical Injection Use and HIV 

in Sub-Saharan Africa 

Vinod Mishra1

Shane Khan1

Li Liu2

Benny Kottiri3

 

Macro International Inc. 

Calverton, Maryland, USA 

October 2008 

Corresponding author: Vinod Mishra, Demographic and Health Research Division, Macro International Inc., 

11785 Beltsville Drive, Suite 300, Calverton, MD 20705; Phone: 301-572-0220; Fax: 301-572-0999; 

Email: vinod.mishra@macrointernational.com. 

1

 Macro International Inc., Calverton, Maryland, USA 

2

 Johns Hopkins University, Baltimore, Maryland, USA 

3

 United States Agency for International Development, Washington, DC, USA
Editor: Bryant Robey 

Document Production: Yuan Gu 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the 

MEASURE DHS project (#GPO-C-00-03-00002-00). The views expressed are those of the authors and 

do not necessarily reflect the views of USAID, PEPFAR, or the United States Government. 

Recommended citation: 

Mishra, Vinod, Shane Khan, Li Liu, and Benny Kottiri. 2008. Medical Injection Use and HIV in SubSaharan Africa. DHS Comparative Reports No. 21. Calverton, Maryland, USA: Macro International Inc. 
iii 

Contents 

Contents ......................................................................................................................................... iii 

Tables .............................................................................................................................................. v 

Preface........................................................................................................................................... vii 

Acknowledgements ........................................................................................................................ ix 

Executive Summary ....................................................................................................................... xi 

1 Introduction ............................................................................................................................. 1 

2 Background .............................................................................................................................. 3 

3 Methods ................................................................................................................................... 5 

4 Results ..................................................................................................................................... 7 

5 Key Findings and Conclusions .............................................................................................. 23 

6 References ............................................................................................................................. 25 

v 

Tables 

Table 1. Knowledge of avoiding HIV infection .......................................................................... 8

Table 2. Perceived risk of acquiring HIV from injections or blood transfusions ........................ 9

Table 3. Received medical injections in the recent past ............................................................ 10

Table 4. Number of medical injections received in the recent past ........................................... 11

Table 5. Differentials in use of multiple medical injections among women ............................. 12

Table 6. Differentials in use of multiple medical injections among men .................................. 13

Table 7. Medical injections from a health professional among women .................................... 14

Table 8. Medical injections from a health professional among men ......................................... 15

Table 9. Use of new needles ...................................................................................................... 16

Table 10. Blood transfusions ....................................................................................................... 17

Table 11. HIV prevalence by knowledge of avoiding HIV infection .......................................... 18

Table 12. HIV prevalence by receipt of medical injections ......................................................... 20

Table 13. HIV prevalence by receipt of blood transfusions ........................................................ 21

vii 

Preface 

One of the most significant contributions of the MEASURE DHS program is the creation of an 

internationally comparable body of data on the demographic and health characteristics of populations in 

developing countries. The DHS Comparative Reports series examines these data across countries in a 

comparative framework. The DHS Analytical Studies series focuses on specific topics. The principal 

objectives of both series are to provide information for policy formulation at the international level and to 

examine individual country results in an international context. Whereas Comparative Reports are 

primarily descriptive, Analytical Studies have a more analytical approach. 

The Comparative Reports series covers a variable number of countries, depending on the availability of data sets. Where possible, data from previous DHS surveys are used to evaluate trends over 

time. Each report provides detailed tables and graphs organized by region. Survey-related issues such as 

questionnaire comparability, survey procedures, data quality, and methodological approaches are addressed as needed. 

The topics covered in Comparative Reports are selected by MEASURE DHS staff in conjunction 

with the U.S. Agency for International Development. Some reports are updates of previously published 

reports. 

It is anticipated that the availability of comparable information for a large number of developing 

countries will enhance the understanding of important issues in the fields of international population and 

health by analysts and policymakers. 

Ann Way 

Project Director 

ix 

Acknowledgements 

Authors thank Bryant Robey for his comments and editorial help and Yuan Gu for research 

assistance and formatting the report. 

xi 

Executive Summary 

This report describes the extent of use of medical injections and blood transfusions, 

characteristics of medical injection users, and associated knowledge and perceptions about how to avoid 

HIV infection among adult women and men in 10 sub-Saharan African countries. It also examines the 

association between number of medical injections received and HIV serostatus. The analysis is based on 

data from eight Demographic and Health Surveys (DHS): Kenya, Ghana, Burkina Faso, Cameroon, 

Lesotho, Malawi, Ethiopia, and Zimbabwe, and two AIDS Indicator Surveys (AIS): Tanzania and 

Uganda, conducted between 2003 and 2006. 

In most countries studied, receiving multiple medical injections is significantly positively 

associated with being HIV-infected, for both women and men. Ever having received a blood transfusion 

also tends to be positively associated with being HIV-infected. 

The study also finds that knowledge that HIV infection can be avoided by avoiding injections, 

including medical injections, avoiding having sex with injecting drug users (IDUs), and avoiding blood 

transfusion remains low in most countries studied. Few adults perceive the risk of HIV infection from 

having medical injections or blood transfusion. 

A considerable proportion of adults reported receiving medical injections. Among women, 

between 30 percent (in Malawi) and 50 percent (in Uganda) received medical injections in the 12 months 

preceding the survey. In all countries, men are less likely than women to receive medical injections. Men 

are also slightly less likely to receive medical injections from health professionals. Urban and more 

educated women are more likely to receive three or more recent medical injections, but these associations 

are weaker among men. As expected, adults who were chronically ill or reported having a sexually 

transmitted infection (STI) in the past year are more likely to have received medical injections. 

 In most countries a large majority of medical injections received by women and men are from 

new needles, with the notable exception of Lesotho where 27 percent of men did not receive their last 

medical injection from a new needle. In Uganda and Cameroon, 5 and 6 percent of women and 2 and 4 

percent of men, respectively, reported having lifetime exposure to blood transfusions. 

The study finds no clear association between HIV serostatus and knowledge about avoiding HIV 

infection by avoiding injections, or avoiding having sex with IDUs. In some of the countries studied, 

people who know about avoiding HIV infection by avoiding blood transfusions are more likely to be 

HIV-positive, but among women in Zimbabwe and men in Lesotho the reverse is true. 

The study provides information on the extent of knowledge of injection-related risk of HIV 

transmission and presents characteristics of people receiving medical injections in selected countries in 

sub-Saharan Africa. The results show that the knowledge about the risk of HIV infection from unsafe 

injections and blood transfusions is low despite years of HIV/AIDS education efforts. The results 

showing a positive association between receiving either medical injections or blood transfusion and being 

HIV-infected suggest that unsafe medical injections and unsafe blood transfusions as potential modes of 

HIV transmission deserve continued research and programmatic attention. Program priorities in subSaharan Africa may focus on promoting knowledge of potential risks of HIV and other infections from 

unsafe injections and blood transfusions, rational use of medical injections, implementation of the 

national injection safety and blood safety guidelines, and further scale up of medical injection safety and 

blood safety programs. 

1 

1 Introduction 

This report describes the extent of use of medical injections,1 and associated knowledge and 

perceptions of HIV risks, and examines the association between number of medical injections received 

and HIV serostatus among adult women and men in 10 sub-Saharan African countries. The data come 

from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS), which provide a 

basis for cross-country comparisons. The key questions that we attempt to answer are: (1) what are the 

prevalence and patterns of medical injection use across these countries, and (2) what is the association 

between medical injections and HIV infection across the surveys? 

In sub-Saharan Africa it is widely accepted that a large majority of HIV infections are attributable 

to sexual transmission, but the relative role of non-sexual transmission of HIV infection is less clear. 

Among the non-sexual routes of transmission, blood transfusion and injecting drug use are known risk 

factors for HIV infection (Mathers et al. 2008; Aceijas et al. 2004; Quigley et al. 1997; Mann et al. 1986; 

Kiwanuka et al. 2004; Corbett et al. 2002; Baggaley et al. 2006; Moore et al. 2001; Adejuyigbe et al. 

2003). The role of unsafe2

 medical injections, however, is not fully understood, as studies have been 

limited in number and scope, and results have been inconsistent. 

 

1 The term “medical injection” is used to refer to injections received for health care needs. This is to differentiate 

from injections received for other purposes, such as intravenous drug use (IDU). A medical injection may be 

received from a health professional (such as a doctor, nurse, or paramedic), from another person who is not a health 

professional, or taken by the person himself/herself. 2

 Injections given with reused syringes and needles without proper sterilization are considered unsafe. 

3 

2 Background 

Medical injections given with re-used, non-sterilized equipment may increase the risk of HIV and 

other infections (Kane et al. 1999). The World Health Organization (WHO) estimates that at least 16 

billion medical injections are administered annually in developing and transitional countries. WHO 

categorizes up to 50 percent of medical injections in developing countries as unsafe, and considers over 

70 percent of them unnecessary (WHO 2008). WHO also estimates that globally unsafe injections cause 

33 percent of new infections with hepatitis B virus (HBV), 42 percent with hepatitis C virus (HCV), and 2 

percent with HIV, accounting for up to 25 million annual new infections with these viruses. 

A study in seven sub-Saharan African countries found that in five of the countries more than half 

of the medical injections were unsafe, defined as reusing syringe, needle, or both without sterilization 

(Simonsen et al. 1999). In another study in rural Cameroon where discarded syringes and needles used for 

HIV-positive patients were tested, 34 of 103 intravenous injection syringes and 2 of 88 intramuscular 

injection syringes were found to be positive on HIV-1 RNA (Apetrei et al. 2006). In experimental studies, 

HIV-1 has been shown to remain viable in syringes for more than six weeks, depending on the volume of 

blood remaining in the syringes and the storage temperature (Heimer and Abdala 2000). 

Despite such safety concerns, the contribution of unsafe medical injections to HIV transmission 

in sub-Saharan African countries continues to be debated. A number of studies have claimed that the 

contribution of medical injections to HIV transmission is small, ranging from only 1 to 3 percent of all 

HIV transmissions (Baggaley et al. 2006; Hauri et al. 2004; Schmid et al. 2004; Gouws et al. 2006; Hutin 

et al. 2003; French et al. 2006). In the global burden of disease study, Hauri and colleagues (2004) 

estimated that unsafe medical injections and the use of other inadequately sterilized skin piercing 

instruments cause only about 2.5 percent of all HIV infections in sub-Saharan Africa. In Kenya medical 

injections are reported to cause only an estimated 0.6 percent of incident HIV infections, and blood 

transfusions an additional 0.2 percent (Gouws et al. 2006). 

Several other studies have argued that unsafe medical injections cause a much greater share of 

HIV transmissions in sub-Saharan Africa (Brody 2004; Gisselquist 2002, 2007; Gisselquist et al. 2002a, 

2002b; Gisselquist and Potterat 2004; Gisselquist et al. 2004; Gisselquist et al. 2006). Using data from 

percutaneous exposures among U.S. and European health care workers, Gisselquist (2002) estimated the 

average rate of HIV-1 transmission from unsafe medical injections at 2.3 per 100 exposure events, a 

figure that would imply a much higher proportion of HIV infections due to unsafe injections than 

previously estimated. Gisselquist and colleagues (2002c) estimated that 20 to 40 percent of HIV 

infections are due to unsafe injections, while 20 to 29 percent of HIV infections among women and 30 to 

35 percent among men in Africa are due to sexual transmission. Schmid and colleagues (2004), however, 

have argued that Gisselquist and others may have overestimated HIV transmission efficiency due to 

unsafe medical injections. 

Previous empirical studies analyzing the association between medical injections and risk of HIV 

infection also have found mixed results. A positive relationship between unsafe medical injections and 

HIV infection has been observed in some settings (Mann et al. 1986; Deuchert and Brody 2006; Barongo 

et al. 1992). In Kenya, for example, women who received a tetanus injection for their most recent birth in 

the past five years were about twice as likely to be HIV-positive as those who did not receive a tetanus 

injection (Deuchert and Brody 2006). Similarly in Mwanza region of Tanzania, receiving medical 

injections in last 12 months was found to be positively associated with HIV prevalence (Barongo et al. 

1992). However, some other studies have failed to find such an association between medical injections 

and HIV infection (Bulterys et al. 1994; Lopman et al. 2005; Wawer et al. 1994). The lack of significant 

association was also documented in a cohort study in Uganda, where the rate ratio of HIV incidence 
4 

comparing individuals with and without medical injections was 1.05 (95% confidence interval: 0.75-1.46) 

(Kiwanuka et al. 2004). 

Schmid and colleagues (2004) have argued that the relationship between medical injections and 

prevalent HIV infection may be the result of reverse causality, in that people living with HIV may be sick 

and hence need more medical injections, or confounding, in that, for example, a person might receive 

injections for a sexually transmitted infection (STI) which is a cofactor for HIV infection. 
5 

3 Methods 

The data for this study are from the DHS and AIS surveys for 10 countries in sub-Saharan Africa. 

The surveys were conducted between 2003 and 2006. They include DHS surveys in Kenya 2003, Ghana 

2003, Burkina Faso 2003, Cameroon 2004, Lesotho 2004, Malawi 2004, Ethiopia 2005, and Zimbabwe 

2006, and AIS surveys in Tanzania 2003/2004 and Uganda 2004/2005. Both the DHS and AIS surveys 

share comparable survey methodology and questionnaires, allowing for comparisons across countries. 

Surveys collect data from nationally-representative probability samples of households, 

interviewing adult women and men. In most surveys, nationally-representative samples of women age 15-

49 and men age 15-59 were interviewed. Analysis in this study has been restricted to women and men age 

15-49 in all 10 countries. The number of individuals who were eligible to be asked about knowledge to 

avoid HIV by avoiding injections, having sex with injecting drug users (IDUs), or blood transfusions 

ranged from 5,691 women in Ghana to 14,070 women in Ethiopia, and from 2,496 men in Lesotho to 

8,010 men in Uganda. 

The majority of these surveys use a two-stage cluster sampling design, often over-sampling 

certain categories of respondents. As samples are not self-weighting and response rates vary, sample 

weights are used to obtain nationally-representative estimates. In tables with HIV serostatus, the analysis 

uses the HIV weight, while in other tables, the individual weights for women and men are used. Details 

on the survey design and methodology can be found in main survey reports (www.measuredhs.com). 

In general, these surveys gather the following information related to injections, including medical 

injections: knowledge to avoid AIDS by avoiding injections, having sex with IDUs, or blood transfusions; 

perceived risk of acquiring HIV because of a blood transfusion or injection; percentage of individuals 

who had an injection in the last 12 months; number of injections received in the past 12 months; 

percentage of individuals who received three or more injections in the recent past; percentage of 

individuals who received a recent injection from a health professional; percentage who received the last 

medical injection with a new needle; and percentage of women and men who received blood transfusion. 

Not all information is available in all 10 countries examined in this report. 

We first apply descriptive analyses to present the distribution of variables related to injections 

among women and men in each country. We then perform cross tabulations between these variables and 

key socio-demographic variables, including age, education, wealth, residence, knowledge to avoid AIDS 

by avoiding injections, whether suffering from chronic disease, and whether having an STI or symptoms 

of an STI in the past 12 months. 

Finally, we apply chi-square tests and the corresponding p-values to examine the association 

between HIV prevalence and several major injection variables, such as knowledge to avoid HIV by 

avoiding injections, having sex with IDUs, or blood transfusion; recent medical injection history; and 

blood transfusion history. Analyses involving HIV serostatus only include respondents tested for HIV in 

the surveys, while other analyses include all respondents (see individual tables for details). 
6 
7 

4 Results 

Table 1 shows the percentage of women and men age 15-49 who know that HIV infection can be 

prevented by avoiding injections, including medical injections, avoiding having sex with IDUs, or 

avoiding blood transfusions. Both women and men perform poorly on all three indicators. In the 10 

countries studied, only 2-13 percent of women and 3-17 percent of men report having knowledge of any 

of these three means to avoid HIV. Among the three, knowledge of avoiding sex with IDUs is the lowest 

across all 10 countries. 
Table 1. Knowledge of avoiding HIV infection 

Percentage of women and men age 15-49 who know that HIV infection can be avoided by avoiding injections, avoiding sex with intravenous drug users (IDUs), and 

avoiding blood transfusions, DHS/AIS 2003-2006 

Women Men 

Knows to avoid HIV infection by avoiding: Knows to avoid HIV infection by avoiding: 

Country/year Injections 

Sex with 

IDUs 

Blood 

transfusions 

Any of the 

three 

means N Injections 

Sex with 

IDUs 

Blood 

transfusions 

Any of the 

three 

means N 

Kenya 2003 5.2 0.3 5.0 9.1 8,195 4.8 1.2 6.8 10.9 3,363 Ghana 2003 4.0 1.1 3.4 7.7 5,691 8.1 2.0 6.0 13.9 4,529 Burkina Faso 2003 0.7 0.2 1.6 2.1 12,477 1.0 1.1 3.2 4.3 3,209 Cameroon 2004 4.4 0.5 5.1 8.6 10,656 6.5 1.1 8.8 13.9 4,815 Tanzania 2003/04 11.1 0.5 4.6 13.0 6,863 14.1 1.2 5.5 17.1 5,659 Lesotho 2004 2.1 0.5 6.9 8.8 7,095 1.3 0.1 5.4 6.2 2,496 Malawi 2004 10.4 1.1 3.5 12.6 11,698 11.4 0.4 3.1 13.1 3,114 Uganda 2004/05 8.2 0.1 2.6 9.7 9,941 9.3 0.3 5.5 12.8 8,010 Ethiopia 2005 9.5 0.8 2.6 12.2 14,070 9.9 1.6 4.4 14.5 5,464 Zimbabwe 2006 2.5 0.4 1.7 4.2 8,907 1.1 0.5 1.2 2.5 6,863 Note: The responses to the three means to avoid HIV infection are not mututally exclusive. 

8 
9 

Table 2 presents how perceived risk of acquiring HIV due to medical injection use or blood 

transfusion varies by selected background characteristics in Kenya. Overall, only 8 percent of Kenyan 

women and 13 percent of Kenyan men report that they have a moderate or high risk of getting HIV 

infection from injection or blood transfusion. Among both women and men, higher levels of education 

and greater media exposure are associated with greater perception of risk of HIV infection from injection 

or blood transfusion. Younger, urban women are more likely to perceive themselves at risk of infection 

due to injection or blood transfusion. In contrast, older, rural men are more likely to have this perception. 

Wealth status is positively associated with women’s risk perception, but this association is less clear 

among men. 

Table 2. Perceived risk of acquiring HIV from injections or blood transfusions 

Percentage of women and men who think that they have a moderate/high risk of getting HIV from injection or blood 

transfusion, by selected background characteristics, Kenya DHS 2003 

Characteristic Women Men 

Age 

15-24 8.4 9.7 

25-34 8.3 15.6 

35-49 6.7 16.7 

Education 

No education 0.4 * 

Primary 6.0 10.5 

Secondary + 14.1 18.3 

Wealth status 

Lowest 2.8 10.7 

Second 5.3 6.7 

Middle 5.5 22.1 

Fourth 10.0 13.5 

Highest 12.9 13.6 

Residence 

Urban 9.8 9.5 

Rural 7.2 14.8 

Regular exposure to media 

Yes 13.1 16.0 

No 5.2 10.4 

Total 7.8 13.4 

Number 1,979 485 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 
10 

Table 3 shows the percentage of adult women and men in eight countries with available data who 

had an injection in the recent past (in the last 3 months for Burkina Faso, Cameroon, and Lesotho; in the 

last 6 months for Zimbabwe; and in the last 12 months for Tanzania, Malawi, Uganda, and Ethiopia). 

Injection use in the recent past was lower among men than women in all eight countries. In the four 

countries with information for either the last 3 or 6 months, injection use among women and men was 

below 20 percent in all cases. Among the four countries with information on injection use in the last 12 

months, injection use was above 25 percent for women in all four, and for men in two of the countries 

(Tanzania and Uganda). 

Table 3. Received medical injections in the recent past 

Percentage of women and men age 15-49 who had a medical injection in the last 12 months, 

DHS/AIS 2003-2006 

 Received a medical injection in last 12 months 

Women Men 

Country/year Percent N Percent N 

Burkina Faso 2003a 11.6 12,477 n/a n/a 

Cameroon 2004a 19.7 10,656 17.4 4,815 

Tanzania 2003/04 38.3 6,863 26.7 5,659 

Lesotho 2004a 15.5 7,095 5.9 2,496 

Malawi 2004 30.1 11,698 12.6 3,114 

Uganda 2004/05b 49.6 9,941 37.4 8,010 

Ethiopia 2005 26.1 14,070 19.6 5,464 

Zimbabwe 2006c 14.2 8,907 6.5 6,863 a

In the last 3 months 

b

By a health professional 

c

In the last 6 months 

n/a: not available
11 

Table 4 presents the distribution of number of medical injections received in the past 12 months, 

for adult women and men. The majority did not receive any injections in the recent past. In most of the 

seven countries with data, less than 13 percent of women and men had three or more medical injections in 

the recent past, with the exception of Uganda where 32 percent of women and 24 percent of men received 

three or more injections from a health professional in the last 12 months.3

 

Table 4. Number of medical injections received in the recent past 

Percent distribution of women and men age 15-49 by number of medical injections received in the last 12 months, 

DHS/AIS 2003-2006 

 Number of medical injections 

Women Men 

Country/year 0 1 2 3+ N 0 1 2 3+ N 

Burkina Faso 2003a 88.4 5.7 2.9 3.0 12,472 n/a n/a n/a n/a n/a 

Cameroon 2004a 80.7 8.5 4.1 6.7 10,656 83.1 7.1 3.4 6.4 4,815 

Lesotho 2004a 84.5 11.3 2.8 1.4 7,095 94.1 3.6 0.8 1.4 2,496 

Malawi 2004 70.0 10.6 8.5 11.0 11,698 87.4 5.9 3.5 3.2 3,114 

Uganda 2004/05b 50.4 8.2 9.2 32.2 9,941 62.6 6.5 7.1 23.9 8,010 

Ethiopia 2005 73.9 6.8 6.7 12.6 14,070 80.4 4.6 4.8 10.2 5,464 

Zimbabwe 2006c 85.8 7.1 4.5 2.6 8,907 93.5 3.0 1.4 2.1 6,863 a

In the last 3 months 

b

By a health professional 

c

In the last 6 months 

n/a: not available

 

3

 The 2004/04 survey in Uganda only asked about medical injections received from a health professional. The 

numbers for Uganda are therefore not strictly comparable to other countries in Table 4. 
12 

Tables 5 and 6 show how the percentage of women and men who had three or more injections in 

the recent past (whether 3 months, 6 months, or 12 months) varies by selected characteristics. Among 

women (Table 5) in the seven countries with available data, those age 25-34 are more likely than other 

age groups to have multiple injections in the recent past. Women with more education are also more 

likely to have injections. In addition, recent multiple injection use is positively associated with wealth 

among women in Burkina Faso, Cameroon, Ethiopia, and Uganda, but less so in the other three countries. 

Urban women are also more likely to receive three or more recent injections. Women with knowledge 

about avoiding HIV by avoiding injections and women having an STI in the last 12 months are both more 

likely to have three or more recent injections. Also, in the four countries with data on chronic illness, 

women suffering from a chronic illness for at least 3 of the last 12 months are, as expected, more likely to 

have received three or more recent injections. 

Table 5. Differentials in use of multiple medical injections among women

Percentage of women age 15-49 who received three or more medical injections in the recent past, by selected characteristics, 

DHS/AIS 2003-2006 

 Received 3+ medical injections in the last: 

3 months 6 months 12 months 

Characteristic Burkina Faso Cameroon Lesotho Zimbabwe1 Malawi Ethiopia Uganda1,2 

Age 

15-24 2.6 5.3 1.0 2.5 10.1 10.1 28.2 

25-34 3.6 7.6 1.9 2.7 13.7 14.5 35.3 

35-49 2.9 8.5 1.6 2.7 9.1 14.3 34.7 

Education 

No education 2.5 3.7 0.6 0.6 10.0 11.6 26.3 

Primary 4.4 6.5 1.3 2.1 10.8 13.9 32.8 

Secondary + 5.1 8.8 1.7 3.0 13.4 16.4 37.2 

Wealth status 

Lowest 1.1 3.7 1.0 1.8 10.1 9.2 28.7 

Second 2.5 5.1 1.4 2.3 10.8 9.0 29.4 

Middle 2.9 5.9 1.3 3.0 10.3 11.7 30.3 

Fourth 2.7 8.0 1.4 2.7 10.5 13.6 32.4 

Highest 4.9 9.8 1.7 3.0 12.9 17.6 38.2 

Residence 

Urban 4.3 8.3 1.6 3.0 13.2 16.6 37.2 

Rural 2.6 4.9 1.4 2.3 10.5 11.8 31.3 

Knows to avoid AIDS by 

avoiding injections 

Yes 3.4 10.6 3.7 7.6 11.5 13.9 35.4 

No 3.0 6.6 1.4 2.5 10.9 12.5 31.9 

Suffers from chronic illness 

Yes n/a 18.8 n/a 10.7 15.6 n/a 42.8 

No n/a 6.2 n/a 2.5 10.7 n/a 31.2 

Had STI in last 12 months 

Yes 9.1 12.3 2.5 4.5 12.5 25.4 40.8 

No 2.7 6.1 1.3 2.4 10.9 12.4 28.8 

Total 3.0 6.7 1.4 2.6 11.0 12.6 32.2 

Number 12,477 10,656 7,095 8,907 11,698 14,070 9,941 1

Chronic illness asked only for 18+ 

2

By a health professional 

n/a: not available
13 

Among men (Table 6) in the six countries with available data, the associations between the 

percentage receiving three or more medical injections in the recent past and men’s age and level of 

education are less clear. Uganda is the exception, where the percentage of men with three or more recent 

injections from a health professional increases with age and with education. There is no clear pattern in 

the percentage of men with three or more recent injections by men’s wealth status or place of residence. 

In Cameroon, Lesotho, Ethiopia, and Uganda, men who know about avoiding HIV by avoiding injections 

are more likely to have three or more recent injections, but this association is not observed in Malawi and 

Zimbabwe. In all six countries, as expected, men with a chronic illness or an STI in the last 12 months are 

more likely to have had three or more recent injections. 

Table 6. Differentials in use of multiple medical injections among men 

Percentage of men age 15-49 who received three or more medical injections in the recent past, by selected characteristics, 

DHS/AIS 2003-2006 

 Received 3+ medical injections in the last: 

3 months 6 months 12 months 

Characteristic Cameroon Lesotho Zimbabwe1,2 Malawi Ethiopia Uganda1,2 

Age 

15-24 4.5 0.7 1.4 3.2 9.9 20.8 

25-34 8.5 2.4 2.2 3.5 10.5 25.2 

35-49 7.1 2.0 3.7 2.9 10.4 27.0 

Education 

No education 5.2 1.0 1.0 1.9 7.9 19.5 

Primary 6.3 1.9 2.2 3.6 12.4 23.0 

Secondary + 6.6 0.8 2.1 2.9 10.4 26.7 

Wealth status 

Lowest 3.3 1.8 1.5 3.3 9.4 20.7 

Second 5.7 2.3 1.6 3.3 12.9 22.1 

Middle 6.8 1.2 1.0 1.9 9.7 23.4 

Fourth 8.0 0.8 2.4 3.2 9.5 24.4 

Highest 6.6 1.3 3.5 4.3 9.6 27.1 

Residence 

Urban 7.2 1.1 3.0 3.5 9.5 26.4 

Rural 5.2 1.5 1.5 3.2 10.3 23.4 

Knows to avoid AIDS by 

avoiding injections 

Yes 10.6 1.5 1.6 2.3 13.8 27.3 

No 6.1 0.0 2.1 3.4 9.8 23.5 

Suffers from chronic illness 

Yes 21.9 n/a 18.4 10.2 n/a 33.6 

No 5.6 n/a 2.0 3.0 n/a 23.0 

Had STI in last 12 months 

Yes 14.7 4.4 6.1 9.7 11.8 36.3 

No 5.7 1.1 1.9 2.9 10.2 21.3 

Total 6.4 1.4 2.1 3.2 10.2 23.9 

Number 4,815 2,496 6,863 3,106 5,464 8,010 1

Chronic illness asked only for 18+ 

2

By a health professional 

n/a: not available
14 

Among women (Table 7) and men (Table 8) who received medical injections recently, nearly all 

of the injections are administered by a health professional. Men are slightly less likely than women to 

receive injections from a health professional, but in all cases at 90 percent or higher. The percentage 

receiving injections from health professionals varies little by respondents’ characteristics, except in 

Malawi, where only 83 percent of men without education receive injections administered by a health 

professional. 

Table 7. Medical injections from a health professional among women

Among women age 15-49 who received any medical injections in the recent past, percentage who received all injections 

from a health professional, by selected characteristics, DHS/AIS 2003-2006 

 Percentage who received all medical injections from a health professional 

Characteristic Burkina Faso1 Malawi1 Ethiopia Zimbabwe2 Lesotho 

Age 

15-24 98.6 95.3 97.6 98.5 96.6 

25-34 98.7 95.6 96.5 99.7 97.3 

35-49 98.4 93.3 96.6 98.1 95.3 

Education 

No education 98.9 95.3 96.7 100.0 * 

Primary 97.7 95.2 97.2 99.1 96.3 

Secondary + 97.0 94.3 97.8 98.6 96.6 

Wealth status 

Lowest 99.4 93.4 96.0 99.6 95.2 

Second 98.2 95.4 96.3 100.0 95.4 

Middle 98.9 95.4 97.0 99.1 98.2 

Fourth 99.2 94.8 95.3 98.3 97.7 

Highest 97.8 95.9 98.8 97.8 95.4 

Residence 

Urban 97.5 98.9 98.7 97.5 96.7 

Rural 99.0 94.3 96.5 99.6 96.4 

Knows to avoid AIDS by 

avoiding injections 

Yes * 93.6 97.9 95.4 (100.0) 

No 98.6 95.2 96.8 98.9 96.5 

Suffers from chronic illness 

Yes n/a 94.7 n/a 95.5 n/a 

No n/a 95.1 n/a 98.9 n/a 

Had STI in last 12 months 

Yes 100.0 94.8 92.2 98.8 98.2 

No 98.5 95.1 97.1 98.8 96.1 

Total 98.6 95.1 97.0 98.8 96.5 

Number 1,452 3,518 3,672 1,271 1,098 

Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer 

than 25 unweighted cases and has been suppressed. 

1

Most recent medical injection from a health professional 

2

Chronic illness asked only for 18+ 

n/a: not available 
15 

Table 8. Medical injections from a health professional among men

Among men age 15-49 who received any medical injections in the recent past, percentage who received 

all injections from a health professional, by selected characteristics, DHS/AIS 2003-2006 

 

Percentage who received all medical injections 

from a health professional 

Characteristic Malawi1 Ethiopia Zimbabwe2 Lesotho 

Age 

15-24 90.9 92.5 96.6 91.1 

25-34 89.7 90.6 94.1 87.4 

35-49 96.5 93.2 95.1 (92.7) 

Education 

No education 82.7 92.0 * * 

Primary 90.9 91.2 94.7 89.5 

Secondary + 95.9 94.1 95.6 (92.9) 

Wealth status 

Lowest 94.3 93.8 97.8 * 

Second 90.4 91.9 95.7 (86.2) 

Middle 90.2 87.0 94.7 (86.0) 

Fourth 87.2 95.7 97.0 (93.2) 

Highest 96.4 92.0 92.4 (97.9) 

Residence 

Urban 99.4 91.4 94.6 (91.8) 

Rural 89.6 92.3 96.0 89.8 

Knows to avoid AIDS by avoiding injections 

Yes 90.5 87.0 * * 

No 91.8 93.0 95.3 90.1 

Suffers from chronic illness 

Yes (100.0) n/a 97.3 n/a 

No 91.0 n/a 96.4 n/a 

Had STI in last 12 months 

Yes 97.6 * 96.7 (87.7) 

No 90.9 92.4 95.1 90.9 

Total 91.6 92.2 95.3 90.2 

Number 397 1,077 458 155 

Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is 

based on fewer than 25 unweighted cases and has been suppressed. 

1

Most recent medical injection from a health professional 

2

Chronic illness asked only for 18+ 

n/a: not available 
16 

In Table 9 we examine the use of new needles at last medical injection in the three countries with 

data. Among women and men who had injections in the recent past, the percentage who received them 

with a new needle is above 90 percent, except for women in Ethiopia (89 percent) and men in Lesotho (73 

percent) and Zimbabwe (86 percent). Differentials in the use of new needles by respondents’ 

characteristics are generally small. 

Table 9. Use of new needles 

Among women and men age 15-49 who received any medical injections in the recent past, percentage who 

received the last injection with a new needle, by selected characteristics, DHS/AIS 2003-2006 

 New needle at last injection 

Women Men 

Characteristic Lesotho Ethiopia1 Zimbabwe Lesotho Ethiopia1 Zimbabwe 

Age 

15-24 94.6 91.3 95.5 73.2 92.0 91.9 

25-34 93.5 88.5 95.8 71.5 88.7 75.3 

35-49 89.8 86.7 94.4 (76.0) 92.0 91.7 

Education 

No education * 85.0 (89.7) * 89.0 * 

Primary 93.8 93.9 95.6 70.8 89.8 77.0 

Secondary + 92.2 96.9 95.4 (87.1) 96.0 90.4 

Wealth status 

Lowest 91.9 79.1 98.4 * 95.6 72.4 

Second 89.6 89.0 96.6 (69.1) 84.9 85.5 

Middle 94.8 83.2 95.0 (76.5) 87.0 89.7 

Fourth 93.8 88.4 93.5 (72.7) 92.8 90.4 

Highest 92.8 96.7 94.8 (83.2) 94.9 87.5 

Residence 

Urban 91.9 98.0 93.8 (76.9) 98.0 89.0 

Rural 93.2 86.7 96.3 72.5 89.8 84.0 

Total 92.9 89.1 95.3 73.4 91.1 86.4 

Number 1,098 3,672 1,271 155 1,077 458 

Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on 

fewer than 25 unweighted cases and has been suppressed. 

1

By a health professional 
17 

Table 10 presents the percentage of women and men in Cameroon and Uganda who have ever 

had a blood transfusion, and in Tanzania as well as Cameroon and Uganda, those who had a transfusion in 

the recent past. In Cameroon and Uganda less than 6 percent of women or men have had a blood 

transfusion at all. In all three countries, recent blood transfusions are even rarer. 

Table 10. Blood transfusions 

Percentage of women and men age 15-49 who received a blood transfusion, ever 

or in the last 12 months, DHS/AIS 2003-2006 

 Received blood transfusion 

Women Men 

Country/year Percent N Percent N 

Cameroon 2004 

Ever 5.6 10,656 4.3 4,815 

In the last 5 years 3.7 10,656 2.9 4,815 

Tanzania 2003/04 

Ever n/a n/a n/a n/a 

In the last 12 months 1.2 6,863 0.4 5,659 

Uganda 2004/05 

Ever 4.5 9,941 2.2 8,010 

In the last 12 months 0.8 9,941 0.3 8,010 

n/a: not available 

Table 11 shows the association between a person’s HIV serostatus and the person’s knowledge of 

the ways to avoid HIV infection (by avoiding injections, avoiding having sex with IDUs, and avoiding 

blood transfusions). Women and men who know that avoiding injections can help avoid HIV infection are 

less likely to be HIV-positive, but this association is not statistically significant. In general, there is no 

clear association among either women or men between HIV serostatus and knowledge of how to avoid 

HIV by avoiding sex with IDUs. 

With respect to the association between knowledge of avoiding blood transfusions to avoid HIV 

infection and a respondent’s HIV status, the relationship is significant among men in Lesotho, and among 

women in Malawi, Uganda, and Zimbabwe. However, the direction of the association is not 

straightforward. Men in Lesotho and women in Zimbabwe who know about avoiding blood transfusions 

are less likely to be HIV-positive. But the relationship is reversed in Malawi and Uganda, where women 

who know about avoiding blood transfusions are more likely to be HIV-positive. 
Table 11. HIV prevalence by knowledge of avoiding HIV infection 

HIV prevalence among women and men age 15-49 by knowledge of avoiding HIV infection by avoiding injections, avoiding sex with IDUs, and blood transfusions, DHS/AIS 

2003-2006 

Knowledge of avoiding HIV infection by avoiding: 

Injections Sex with IDUs Blood transfusions 

Country/year/sex Knows 

Does 

not know p-value Knows 

Does 

not know p-value Knows 

Does 

not know p-value

Kenya 2003 

Women 4.8 8.9 0.082 * 8.7 0.305 7.1 8.8 0.481 Men 4.9 4.5 0.828 (0.0) 4.7 0.190 4.7 4.6 0.940 

Ghana 2003 

Women 1.5 2.8 0.281 3.6 2.7 0.667 2.4 2.7 0.795 Men 0.6 1.5 0.163 2.4 1.4 0.471 1.5 1.5 0.923 

Burkina Faso 2003 

Women (0.0) 1.9 0.423 * 1.8 0.002 4.5 1.8 0.099 Men (0.0) 1.9 0.434 (0.0) 1.9 0.413 1.0 1.9 0.546 

Cameroon 2004 

Women 8.2 6.7 0.361 14.3 6.7 0.168 6.8 6.6 0.941 Men 4.2 4.1 0.950 (13.0) 4.0 0.002 5.6 4.0 0.130 

Tanzania 2003/04 

Women 6.6 7.8 0.270 3.2 7.7 0.348 7.4 7.7 0.876 Men 5.0 6.5 0.136 6.0 6.3 0.919 4.5 6.4 0.216 

Lesotho 2004 

Women 23.9 26.5 0.637 * 26.4 0.979 23.7 26.6 0.362 Men * 19.4 0.059 * 19.2 0.535 8.1 20.0 0.001 

Malawi 2004 

Women 14.2 13.2 0.642 (16.7) 13.3 0.589 20.7 13.1 0.044 Men 8.9 10.4 0.443 * 10.3 0.310 11.7 10.1 0.658 

Uganda 2004/05 

Women 6.7 7.5 0.381 * 7.5 0.288 11.8 7.3 0.008 Men 4.4 5.1 0.428 * 5.0 0.292 6.2 4.9 0.246 

Ethiopia 2005 

Women 0.9 2.0 0.059 5.6 1.8 0.101 1.8 1.9 0.951 Men 0.8 0.9 0.791 0.0 0.9 0.426 0.0 1.0 0.137 

Zimbabwe 2006 

Women 15.3 21.3 0.059 (36.0) 21.1 0.068 8.0 21.3 0.001 Men 12.7 14.6 0.678 (14.8) 14.5 0.969 17.5 14.5 0.505 

Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 

18 
19 

We also analyze the relationships between several injection use variables and HIV serostatus 

among women and men. Table 12 shows that in all eight countries with data men who received one or 

more medical injections in the recent past are significantly more likely to be infected with HIV than those 

who did not receive any recent medical injections, with the exception of Ethiopia. The association is also 

positive for women in seven of the eight countries with data, but not statistically significant in Burkina 

Faso, Ethiopia, Malawi, and Tanzania. Similarly, women and men with three or more medical injections 

in the recent past are more likely to be infected with HIV, but the association is not statistically significant 

for women in Burkina Faso and Malawi, and for men in Cameroon, Malawi, and Ethiopia. 

In addition, we examine the associations between HIV status and having all injections from a 

health professional and the use of a new needle at last injection. In most countries studied, these 

relationships are not statistically significant. But in Malawi men with injections all from a health 

professional are more likely to be HIV-positive. This relationship may occur because HIV-positive men 

are more likely to get treatment for HIV and opportunistic infections, and hence receive more medical 

injections. Additional care should be exercised when interpreting this statistic, as the sample size is small. 

The relationship between HIV status and the use of a new needle is only significant among men 

in Zimbabwe, where those whose most recent injection was administered with a new needle are more 

likely to be HIV-positive. While this result is unexpected, the respondent’s HIV status may be due to 

other behaviors, such as higher-risk sex, that preceded the use of a new needle. 
Table 12. HIV prevalence by receipt of medical injections

HIV prevalence among women and men age 15-49 who received a medical injection in the recent past, who received 3+ medical injections in the recent past, who received all recent medical injections from a health professional, and who received their most recent medical injection using a new needle, DHS/AIS 2003-2006 

Recently received a 

medical injection 

Recently received 3+ 

medical injections 

All injections from a health 

care professional1,2 Most recent injection from a new needle1

Country/year/sex Yes No p-value Yes No p-value Yes No p-value Yes No p-valueBurkina Faso 2003a

Women 1.4 1.9 0.444 2.2 1.8 0.734 1.4 * 0.739 n/a n/a n/a Men n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 

Cameroon 2004a

Women 9.7 6.1 0.000 13.5 6.3 0.000 n/a n/a n/a n/a n/a n/a Men 6.2 3.7 0.001 6.3 4.0 0.053 n/a n/a n/a n/a n/a n/a 

Tanzania 2003/04 

Women 8.1 7.4 0.309 n/a n/a n/a n/a n/a n/a n/a n/a n/a Men 8.7 5.4 0.000 n/a n/a n/a n/a n/a n/a n/a n/a n/a 

Lesotho 2004a

Women 35.0 24.7 0.000 49.2 26.0 0.000 32.4 36.2 0.364 32.5 37.2 0.265 Men 44.5 17.6 0.000 (49.9) 18.8 0.000 45.6 * 0.366 44.8 (43.2) 0.859 

Malawi 2004 

Women 15.1 12.6 0.075 14.5 13.2 0.540 15.4 10.3 0.386 n/a n/a n/a Men 16.6 9.3 0.000 14.1 10.1 0.228 17.8 (0.0) 0.015 n/a n/a n/a 

Uganda 2004/05b

Women 8.5 6.4 0.000 10.2 6.1 0.000 8.5 6.4 0.000 n/a n/a n/a Men 6.8 3.9 0.000 8.5 3.9 0.000 6.8 3.9 0.000 n/a n/a n/a 

Ethiopia 2005 

Women 2.3 1.7 0.109 3.2 1.6 0.004 2.3 3.0 0.787 2.5 1.1 0.271 Men 0.8 1.0 0.730 1.4 0.9 0.247 0.9 0.0 0.411 0.9 0.0 0.372 

Zimbabwe 2006c

Women 27.5 20.0 0.000 33.9 20.8 0.000 27.6 30.8 0.799 27.8 23.4 0.509 Men 29.1 13.5 0.000 36.0 14.1 0.000 29.3 * 0.593 32.0 13.0 0.004 

Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1Among those who received any injections in the recent past 2Burkina Faso and Malawi: Most recent medical injection from a health professional aIn the last 3 months bBy a health professional cIn the last 6 months n/a: not available

20 
21 

Blood transfusions are another possible mechanism of HIV exposure. Table 13 shows that in two 

of the three countries with data available—Cameroon and Uganda—having ever received a blood 

transfusion is significantly and positively associated with being HIV-positive among women, but not 

among men. In addition, in Cameroon women who had a blood transfusion in the last five years also are 

significantly more likely to be HIV-positive. 

Table 13. HIV prevalence by receipt of blood transfusions

HIV prevalence among women and men age 15-49 who ever received a blood transfusion, and among those 

who received a blood transfusion in the last 12 months, DHS/AIS 2003-2006 

 

Ever received a blood 

transfusion 

Received a blood transfusion in 

the last 12 months1

Country/year/sex Yes No p-value Yes No p-value

Cameroon 2004 

Women 12.5 6.4 0.000 13.5 6.5 0.000 

Men 4.6 4.1 0.728 5.3 4.1 0.492 

Tanzania 2003/04 

Women n/a n/a n/a 7.5 7.7 0.940 

Men n/a n/a n/a * 6.3 0.901 

Uganda 2004/05 

Women 10.2 7.4 0.032 9.6 7.5 0.500 

Men 3.2 5.1 0.268 * 5.1 0.341 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been 

suppressed. 

1

In the last 5 years for Cameroon

n/a: not available

23 

5 Key Findings and Conclusions 

In most of the sub-Saharan African countries studied, knowledge about avoiding HIV infection 

by avoiding injections, avoiding having sex with IDUs, and avoiding blood transfusions is low. Few 

adults perceive themselves to be at risk of HIV infection due to medical injections or blood transfusion. 

A considerable proportion of adults report receiving medical injections in the recent past, while in 

all countries studied men are less likely than women to receive medical injections. Men are also slightly 

less likely to receive medical injections from health professionals. Women who live in urban areas and 

who are more educated are more likely to have received three or more medical injections in the recent 

past. Among men, the urban/rural and educational differentials are less obvious. Chronically ill adults and 

those who reported having an STI in the past year are, as expected, more likely to receive injections. In 

two of three countries with available data, a large majority of medical injections are from new needles, 

with the exception of Lesotho where 27 percent of men received their last injection from a previously 

used needle. In Uganda, 5 percent of women and 2 percent of men, and in Cameroon 6 percent of women 

and 4 percent of men, report ever having blood transfusions. 

The study finds no clear association between HIV serostatus and knowledge about avoiding HIV 

infection by avoiding injections, including medical injections, or avoiding having sex with IDUs. 

However, people who know about avoiding HIV infection by avoiding blood transfusions are likely to be 

HIV-positive in some countries, with the clear exception of women in Zimbabwe and men in Lesotho, 

where the reverse holds. 

In most countries among women and men, receiving multiple medical injections is significantly 

positively associated with being HIV-infected. In two countries with data, Cameroon and Uganda, ever 

having received a blood transfusion is significantly positively associated with being HIV-infected among 

women. 

Several measurement constraints must be kept in mind when interpreting these findings. First, 

because of the cross-sectional feature of the DHS and AIS surveys, the reported associations may not 

imply causality. For many HIV-positive adults, the infection may have preceded their medical injections 

and other behaviors recorded for the 12 months preceding the survey. Second, some of the observed 

relationships may be due to reverse causality, or to confounding. Reverse causality could result if HIVrelated illness leads to greater use of medical injections; and confounding could result if greater use of 

medical injections occurs due to another risk factor of HIV, such as genital herpes. Third, our analysis is 

based on self-reported numbers of medical injections and some self-reported behaviors. Thus the findings 

may be biased to the extent that men and women misreport information. 

In addition, although the response rates are reasonably high in these surveys, selection bias due to 

non-response is still of concern. If HIV-infected individuals with frequent medical injections were less 

likely to participate in the surveys, then we may have underestimated the association between medical 

injections and HIV infection. However, previous research has found little evidence that chronically ill 

adults are less likely to participate in such surveys or that HIV prevalence levels are significantly 

downwardly biased due to non-response (Mishra et al. 2008). 

Moreover, not all data are available for all 10 of the countries, and in some instances the 

questions asked are not consistent across countries and thus, for some variables, comparisons may not be 

easy to make. Also, because receiving multiple medical injections, blood transfusion, and HIV infection 

are relatively rare events, some of the cross-tabulations result in cells with small numbers of cases, which 

may make the resulting statistics less precise. 
24 

Despite these limitations, the study provides new and detailed comparative information on the 

extent of knowledge of injections-related risk of HIV transmission and presents characteristics of people 

receiving medical injections in several countries in sub-Saharan Africa, where HIV remains a serious 

public health problem. The results show that in most countries the knowledge about the risk of HIV 

infection from unsafe injections and blood transfusions remains low despite years of HIV/AIDS education 

efforts. In most cases the results also show a significant and positive association between receiving 

medical injections or blood transfusion and being HIV-infected. 

The findings suggest that medical injections and blood transfusion as potential modes of HIV 

transmission deserve continued research and programmatic attention. Program priorities in sub-Saharan 

Africa may include focus on promoting knowledge of potential risks of HIV and other infections from 

unsafe injections and blood transfusion, rational use of medical injections, implementation of the national 

injection safety and blood safety guidelines, and further scale up of medical injection safety and blood 

safety programs. 
25 

6 References 

Aceijas C, Stimson GV, Hickman M, Rhodes T. Global overview of injecting drug use and HIV infection 

among injecting drug users. AIDS 2004; 18(17):2295-2303. 

Adejuyigbe EA, Durosinmi MA, Onyia FN, Adeodu OO. Blood transfusion related paediatric HIV/AIDS 

in Ile-Ife, Nigeria. AIDS Care 2003; 15(3):329-335. 

Apetrei C, Becker J, Metzger M, Gautam R, Engle J, Wales AK, Eyong M, Enyong P, Sama M, Foley 

BT, Drucker E, Marx PA. Potential for HIV transmission through unsafe injections. AIDS 2006; 

20(7):1074-1076. 

Baggaley RF, Boily MC, White RG, Alary M. Risk of HIV-1 transmission for parenteral exposure and 

blood transfusion: a systematic review and meta-analysis. AIDS 2006; 20(6):805-812. 

Barongo LR, Borgdorff MW, Mosha FF, Nicoll A, Grosskurth H, Senkoro KP, Newell JN, Changalucha 

J, Klokke AH, Killewo JZ, et al. The epidemiology of HIV-1 infection in urban areas, roadside 

settlements and rural villages in Mwanza Region, Tanzania. AIDS 1992; 6(12):1521-1528. 

Brody S. Declining HIV rates in Uganda: due to cleaner needles, not abstinence or condoms. Int J STD 

AIDS 2004; 15(7):440-441. 

Bulterys M, Chao A, Habimana P, Dushimimana A, Nawrocki P, Saah A. Incident HIV-1 infection in a 

cohort of young women in Butare, Rwanda. AIDS 1994; 8(11):1585-1591. 

Corbett EL, Steketee RW, ter Kuile FO, Latif AS, Kamali A, Hayes RJ. HIV-1/AIDS and the control of 

other infectious diseases in Africa. Lancet 2002; 359(9324):2177-2187. 

Deuchert E, Brody S. The role of health care in the spread of HIV/AIDS in Africa: evidence from Kenya. 

Int J STD AIDS 2006; 17(11):749-752. 

French K, Riley S, Garnett G. Simulations of the HIV epidemic in sub-Saharan Africa: sexual 

transmission versus transmission through unsafe medical injections. Sex Transm Dis 2006; 33(3):127-

134. 

Gisselquist D, Minkin SF, Okwuosah A, Salerno L, Minja-Trupin C. Unsafe injections and transmission 

of HIV-1 in sub-Saharan Africa. Lancet 2004; 363(9421):1648-1649. 

Gisselquist D, Potterat JJ. Review of evidence from risk factor analyses associating HIV infection in 

African adults with medical injections and multiple sexual partners. Int J STD AIDS 2004; 15(4):222-233. 

Gisselquist D, Rothenberg R, Potterat J, Drucker E. HIV infections in sub-Saharan Africa not explained 

by sexual or vertical transmission. Int J STD AIDS 2002a; 13(10):657-666. 

Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked 

in developing countries. BMJ 2002b; 324(7331):235. 

Gisselquist D, Potterat JJ, Epstein P, Vachon F, Minkin SF. AIDS in Africa. Lancet 2002c; 

360(9343):1422-1423. 
26 

Gisselquist D, Upham G, Potterat JJ. Efficiency of human immunodeficiency virus transmission through 

injections and other medical procedures: evidence, estimates, and unfinished business. Infect Control 

Hosp Epidemiol 2006; 27(9):944-952. 

Gisselquist D. How much do blood exposures contribute to HIV prevalence in female sex workers in subSaharan Africa, Thailand and India? Int J STD AIDS 2007; 18(9):581-588. 

Gisselquist DP. Estimating HIV-1 transmission efficiency through unsafe medical injections. Int J STD 

AIDS 2002; 13(3):152-159. 

Gouws E, White PJ, Stover J, Brown T. Short term estimates of adult HIV incidence by mode of 

transmission: Kenya and Thailand as examples. Sex Transm Infect 2006; 82 Suppl 3:iii51-iii55. 

Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections 

given in health care settings. Int J STD AIDS 2004; 15(1):7-16. 

Heimer R, Abdala N. Viability of HIV-1 in syringes: implications for interventions among injection drug 

users. AIDS Read 2000; 10:410-417. 

Hutin YJ, Hauri AM, Armstrong GL. Use of injections in healthcare settings worldwide, 2000: literature 

review and regional estimates. BMJ 2003; 327(7423):1075. 

Kane A, Lloyd J, Zaffran M, Simonsen L, Kane M. Transmission of hepatitis B, hepatitis C and human 

immunodeficiency viruses through unsafe injections in the developing world: model-based regional 

estimates. Bull World Health Organ 1999; 77(10):801-807. 

Kiwanuka N, Gray RH, Serwadda D, Li X, Sewankambo NK, Kigozi G, Lutalo T, Nalugoda F, Wawer 

MJ. The incidence of HIV-1 associated with injections and transfusions in a prospective cohort, Rakai, 

Uganda. AIDS 2004; 18(2):342-344. 

Lopman BA, Garnett GP, Mason PR, Gregson S. Individual level injection history: a lack of association 

with HIV incidence in rural Zimbabwe. PLoS Med 2005; 2(2):e37. 

Mann JM, Francis H, Quinn TC, Bila K, Asila PK, Bosenge N, Nzilambi N, Jansegers L, Piot P, Ruti K, 

et al. HIV seroprevalence among hospital workers in Kinshasa, Zaire. Lack of association with 

occupational exposure. JAMA 1986; 256(22):3099-3102. 

Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, 

Tyndall M, Toufik A, Mattick RP; 2007 Reference Group to the UN on HIV and Injecting Drug Use. 

Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. 

Lancet 2008; 372(9651):1733-1745. 

Mishra V, Barrere B, Hong R, Khan S. Evaluation of bias in HIV seroprevalence estimates from national 

household surveys. Sex Transm Infect 2008; 84: i63-i70. 

Moore A, Herrera G, Nyamongo J, Lackritz E, Granade T, Nahlen B, Oloo A, Opondo G, Muga R, 

Janssen R. Estimated risk of HIV transmission by blood transfusion in Kenya. Lancet 2001; 

358(9282):657-660. 
27 

Quigley M, Munguti K, Grosskurth H, Todd J, Mosha F, Senkoro K, Newell J, Mayaud P, ka-Gina G, 

Klokke A, Mabey D, Gavyole A, Hayes R. Sexual behaviour patterns and other risk factors for HIV 

infection in rural Tanzania: a case-control study. AIDS 1997; 11(2):237-248. 

Schmid GP, Buvé A, Mugyenyi P, Garnett GP, Hayes RJ, Williams BG, Calleja JG, De Cock KM, 

Whitworth JA, Kapiga SH, Ghys PD, Hankins C, Zaba B, Heimer R, Boerma JT. Transmission of HIV-1 

infection in sub-Saharan Africa and effect of elimination of unsafe injections. Lancet 2004; 

363(9407):482-488. 

Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and 

transmission of bloodborne pathogens: a review. Bull World Health Organ 1999; 77(10):789-800. 

Wawer MJ, Sewankambo NK, Berkley S, Serwadda D, Musgrave SD, Gray RH, Musagara M, Stallings 

RY, Konde-Lule JK. Incidence of HIV-1 infection in a rural region of Uganda. BMJ 1994; 

308(6922):171-173. 

World Health Organization (WHO). Injection Safety Programme. (www.who.int/injection_safety/en/; 

accessed 29 September, 2008). 

www.measuredhs.com; accessed 31 October, 2008. 

DHS Comparative Reports Series 

1. Westoff, Charles F. 2001. Unmet Need at the End of the Century.

2. Westoff, Charles F., and Akinrinola Bankole. 2002. Reproductive Preferences in Developing Countries at 

the Turn of the Century. 

3. Rutstein, Shea O. 2002. Fertility Levels, Trends, and Differentials 1995-1999.

4. Mahy, Mary. 2003. Childhood Mortality in the Developing World: A Review of Evidence from the 

Demographic and Health Surveys. 

5. Westoff, Charles F. 2003. Trends in Marriage and Early Childbearing in Developing Countries. 

6. Rutstein, Shea O., and Kiersten Johnson. 2004. The DHS Wealth Index.

7. Yoder, P. Stanley, Noureddine Abderrahim, and Arlinda Zhuzhuni. 2004. Female Genital Cutting in the 

Demographic and Health Surveys: A Critical and Comparative Analysis. 

8. Stallings, Rebecca. 2004. Child Morbidity and Treatment Patterns. 

9. Rutstein, Shea O., and Iqbal H. Shah. 2004. Infecundity, Infertility, and Childlessness in 

Developing Countries. 

10. Mukuria, Altrena, Jeanne Cushing, and Jasbir Sangha. 2005. Nutritional Status of Children: Results 

from the Demographic and Health Surveys, 1994–2001. 

11. Mukuria, Altrena, Casey Aboulafia, and Albert Themme. 2005. The Context of Women’s Health: Results 

from the Demographic and Health Surveys, 1994-2001. 

12. Yoder, P. Stanley, Noureddine Abderrahim, and Arlinda Zhuzhini. 2005. L’excision dans les Enquêtes 

Démographiques et de Santé: Une Analyse Comparative. 

13. Garenne, Michel, and Julien Zwang. 2006. Premarital Fertility and Ethnicity in Africa. 

14. Westoff, Charles F. 2006. New Estimates of Unmet Need and the Demand for Family Planning. 

15. Fort, Alfredo L., Monica T. Kothari, and Noureddine Abderrahim. 2006. Postpartum Care: Levels and 

Determinants in Developing Countries. 

16. Khan, Shane, Vinod Mishra, Fred Arnold, and Noureddine Abderrahim. 2007. Contraceptive Trends in 

Developing Countries. 

17. Johnson, Kiersten, and Yuan Gu. Men’s Reproductive Health, Health-Related Behaviors, and 

Involvement in Family Dynamics. (forthcoming) 

18. Garenne, M. Michel. 2008. Fertility Changes in Sub-Saharan Africa. 

19. Khan, Shane, and Vinod Mishra. 2008. Youth Reproductive and Sexual Health. 

20. Kishor, Sunita, and Lekha Subaiya. 2008. Understanding Women’s Empowerment: A Comparative 

Analysis of Demographic and Health Surveys (DHS) Data. 

21. Mishra, Vinod, Shane Khan, Li Liu, and Benny Kottiri. 2008. Medical Injection Use and HIV in SubSaharan Africa.