Accumulated evidence of substantial iatrogenic HIV transmission ignored and mischaracterized 30 June 2011 Devon Brewer, Interdisciplinary Scientific Research Mah and Shelton  seek to defend the hypothesis that sex partner concurrency spawned generalized HIV epidemics. Regrettably, they ignore and mischaracterize major relevant evidence, rendering their argument moot. Mah and Shelton claim “critics of concurrency have not proposed plausible alternative explanations for why the explosive generalized epidemics occurred” (p. 3). Actually, a decade ago, we highlighted the fact that Africans in cities with high HIV prevalences reported low rates of concurrency and those in cities with low HIV prevalences reported higher rates of concurrency [2-3]. We suggested then, and in scores of publications since , that iatrogenic transmission through blood exposures may underlie generalized HIV epidemics in Africa and elsewhere, and provided evidence consistent with that notion. Mah and Shelton further assert that “notably, while non-sexual transmission (i.e., iatrogenic or parenteral) likely contributes some new infections in generalized epidemics, empirical evidence continues to mount that non-sexual transmission is not the major contributor of new infections in these epidemics” (p. 5). None of the sources Mah and Shelton cite present any results of studies with comprehensive assessment of both sexual and non-sexual exposures to HIV. It is impossible to know whether a potential mode of transmission is involved without assessing it. Presumptions are not data. However, a growing body of research points to substantial iatrogenic HIV transmission at sites throughout sub-Saharan Africa. In these studies, researchers eliminated or controlled for sexual exposures as possible factors related to HIV infection. These researchers have found that a range of blood exposures are associated with incident or prevalent HIV infection, including medical injections [5-6], tetanus toxoid vaccination [7-9], male and female circumcision [10-11], blood transfusion , and diverse blood exposures in healthcare and cosmetic care [13-15]. Also, there are significant rates of horizontally acquired HIV infection in national probability samples of children under age 5 in Mozambique, Swaziland, and Uganda [14,16-18]. Moreover, Africans who are aware of blood-borne HIV risks are less likely to be infected than those who are unaware . HIV prevalences are highest in countries (southern and east Africa) where few adults know about blood-borne risks and where prevention campaigns (including many funded by USAID) omit information about such risks. To determine modes of HIV transmission with confidence, researchers must assess blood and sexual exposures comprehensively in incident HIV cases and controls, trace their contacts corresponding to such exposures, and sequence the DNA in infected persons’ HIV isolates [20-22]. Until such investigations are completed, it is unscientific, blind prejudice to claim, as Mah and Shelton do, that blood exposures are not significant routes of HIV transmission in sub-Saharan Africa. Devon D. Brewer1 and John J. Potterat2 1Interdisciplinary Scientific Research, Seattle, WA, USA; email@example.com 2Independent consultant, Colorado Springs, CO, USA; firstname.lastname@example.org References 1. Mah TL, Shelton JD: Concurrency revisited: increasing and compelling epidemiological evidence. J Int AIDS Soc 2011, 14:33. 2. Rothenberg R, Potterat J, Gisselquist D: Concurrency and sexual transmission. AIDS 2002, 16:678-679. 3. Lagarde E, Auvert B, Carael M, Laourou M, Ferry B, Akam E, Sukwa T, Morison L, Maury B, Chege J, N'Doye I, Buve A: Concurrent sexual partnerships and HIV prevalence in five urban communities of sub-Saharan Africa. AIDS 2001, 15:877-884. 4. Potterat JJ: AIDS epidemiology in Africa: a changing of the guard. Int J STD AIDS 2009, 20:812-815. 5. St Lawrence JS, Klaskala W, Kankasa C, West JT, Mitchell CD, Wood C: Factors associated with HIV prevalence in a pre-partum cohort of Zambian women. Int J STD AIDS 2006, 17:607-613. 6. Gisselquist D: Points to consider: Responses to HIV/AIDS in Africa, Asia, and the Caribbean. Adonis and Abbey Publishers Ltd, London; 2007. 7. Deuchert E, Brody S: The role of health care in the spread of HIV/AIDS in sub-Saharan Africa: Evidence from Kenya. Int J STD AIDS 2006, 17:749-752. 8. Deuchert E: Maternal health care and the spread of AIDS in Burkina Faso and Cameroon. World Health Pop 2007, 9:55-72. 9. Brody S: The unhealthy attempts by CDC and WHO to deny the importance of HIV transmission through unsafe health care. Int J STD AIDS 2009, 20:70-72. 10. Brewer DD, Potterat JJ, Roberts JM, Brody S: Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania. Ann Epidemiol 2007, 17:217-226. 11. Brewer DD, Potterat JJ, Roberts JMJ, Brody S: Circumcision-related HIV risk and the unknown mechanism of effect in the male circumcision trials. Ann Epidemiol 2007, 17:928- 929. 12. Vaz P, Pedro A, Le Bozec S, Macassa E, Salvador S, Biberfeld G, Blanche S, Andersson S: Nonvertical, nonsexual transmission of human immunodeficiency virus in children. Pediatr Infect Dis J 2010, 29:271-274. 13. Peters EJ, Brewer DD, Udonwa NE, Jombo GT, Essien OE, Umoh VA, Otu AA, Eduwem DU, Potterat JJ: Diverse blood exposures associated with incident HIV infection in Calabar, Nigeria. Int J STD AIDS 2009, 20:846-851. 14. Okinyi M, Brewer DD, Potterat JJ: Horizontally acquired HIV infection in Kenyan and Swazi children. Int J STD AIDS 2009, 20:852-857. 15. Brewer DD, Potterat JJ, Okinyi M: Data trump speculation and distortion of HIV transmission routes in sub-Saharan Africa. Int J STD AIDS 2011, 22:118-120. 16. Brewer DD, Gisselquist D, Brody S, Potterat JJ: Investigating iatrogenic HIV transmission in Ugandan children. J Acquir Immune Defic Syndr 2007, 45:253-254. 17. Uganda Ministry of Health, ORC Macro: Uganda HIV/AIDS Sero-behavioural Survey 2004-2005. Ministry of Health and ORC Macro, Calverton, Maryland, USA; 2006. 18. Instituto Nacional de Saúde (INS), Instituto Nacional de Estatística (INE), ICF Macro: Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. INS, INE, and ICF Macro; 2010. 19. Brewer DD: Knowledge of blood-borne transmission risk is inversely associated with HIV infection in sub-Saharan Africa. J Infect Dev Ctries 2011, 5:182-198. 20. Brewer DD, Rothenberg RB, Potterat JJ, Brody S, Gisselquist D: HIV epidemiology in sub-Saharan Africa: rich in conjecture, poor in data. International Journal of STD and AIDS 2004, 15:63-65. 21. Brody S, Potterat JJ: Establishing valid AIDS monitoring and research in countries with generalized epidemics. Int J STD AIDS 2004, 15:1-6. 22. Brewer DD, Hagan H, Sullivan DG, Muth SQ, Hough ES, Feuerborn NA, Gretch DR: Social structural and behavioral underpinnings of hyperendemic Hepatitis C virus transmission in drug injectors. J Infect Dis 2006, 194:764-772. Competing interests We declare no competing interests.