{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T05:05:57Z","timestamp":1772168757015,"version":"3.50.1"},"reference-count":61,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2012,7,13]],"date-time":"2012-07-13T00:00:00Z","timestamp":1342137600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/3.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns4:p>\n                    <ns4:bold>Background:<\/ns4:bold>\n                    In prior research, Africans who knew about blood-borne risks were modestly less likely to be HIV-infected than those who were not aware of such risks.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Objectives\/Methods:<\/ns4:bold>\n                    I examined the association between knowledge of specific HIV transmission modes and prevalent HIV infection with data from the 2009 Mozambique AIDS Indicator Survey.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Results:<\/ns4:bold>\n                    Respondents displayed high awareness of blood exposures and vaginal sex as modes of HIV transmission. However, only about half of respondents were aware of anal sex as a way HIV can be transmitted. After adjustments for demographics and sexual behaviors, respondents who knew that HIV could spread by contact with infected blood or by sharing injection needles or razor blades were less likely to be infected than those who did not know about these risks. Respondents who knew about sexual risks were as, or more, likely to be HIV infected as those who did not know about sexual risks. Also, children of HIV-uninfected mothers were less likely to be infected if their mothers were aware of blood-borne HIV risks than if their mothers were unaware.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Conclusion:<\/ns4:bold>\n                    HIV education campaigns in Mozambique and elsewhere in sub-Saharan Africa should include a focus on risks from blood exposures and anal sex.\n                  <\/ns4:p>","DOI":"10.12688\/f1000research.1-1.v1","type":"journal-article","created":{"date-parts":[[2013,5,9]],"date-time":"2013-05-09T12:33:39Z","timestamp":1368102819000},"page":"1","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":9,"title":["Knowledge of specific HIV transmission modes in relation to HIV infection in Mozambique"],"prefix":"10.12688","volume":"1","author":[{"given":"Devon D","family":"Brewer","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2012,7,13]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"607-613","DOI":"10.1258\/095646206778113050","article-title":"Factors associated with HIV prevalence in a pre-partum cohort of Zambian women.","volume":"17","author":"J St Lawrence","year":"2006","journal-title":"Int J STD AIDS."},{"key":"ref-2","doi-asserted-by":"publisher","first-page":"55-72","DOI":"10.12927\/whp.2007.19344","article-title":"Maternal health care and the spread of AIDS in Burkina Faso and Cameroon.","volume":"9","author":"E Deuchert","year":"2007","journal-title":"World Health Pop."},{"key":"ref-3","doi-asserted-by":"publisher","first-page":"749-752","DOI":"10.1258\/095646206778691167","article-title":"The role of health care in the spread of HIV\/AIDS in sub-Saharan Africa: evidence from Kenya.","volume":"17","author":"E 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Gisselquist","year":"2011"}],"container-title":["F1000Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/f1000research.com\/articles\/1-1\/v1\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/1-1\/v1\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/1-1\/v1\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2018,11,22]],"date-time":"2018-11-22T14:27:16Z","timestamp":1542896836000},"score":1,"resource":{"primary":{"URL":"https:\/\/f1000research.com\/articles\/1-1\/v1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2012,7,13]]},"references-count":61,"URL":"https:\/\/doi.org\/10.12688\/f1000research.1-1.v1","relation":{"has-review":[{"id-type":"doi","id":"10.5256\/f1000research.50.r100","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.50.r50","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.50.r101","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.50.r50","asserted-by":"object"},{"id-type":"doi","id":"10.5256\/f1000research.50.r101","asserted-by":"object"},{"id-type":"doi","id":"10.5256\/f1000research.50.r100","asserted-by":"object"}]},"ISSN":["2046-1402"],"issn-type":[{"value":"2046-1402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2012,7,13]]},"assertion":[{"value":"Indexed","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.5256\/f1000research.50.r50, Suzanne Gaudreault, USAID Health Care Improvement Project, University Research Co., LLC, Bethesda, MD 20814, USA, 17 Jul 2012, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#referee-response-50","order":0,"name":"referee-response-50","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Devon Brewer<\/b>; \n<i>Posted: 19 Jul 2012<\/i>; Thank you very much, Dr. Gaudreault, for your review.I agree that it is possible that some previously tested, infected persons might deny having tested previously and that they might have learned about blood exposures and anal sex as routes of transmission during HIV testing or clinical care. However, several lines of evidence suggest that such \u201cknowledge through denied prior testing\u201d is rare, and that even if this bias were present, it cannot account for the association between knowledge and HIV infection.In Class\u2019 (2012) research, adult HIV patients and parents and other caretakers of HIV infected children in Maputo, Mozambique, responded to open-ended questions about routes of HIV transmission. Fifty-five percent (12\/22) of the adult HIV patients and 62% (16\/26) of parents and caretakers were aware of blood-borne modes of HIV transmission. All respondents aware of blood-borne HIV transmission reported learning of these modes of transmission exclusively from unofficial, non-clinical, non-public health sources, such as \u201con the street.\u201d Class\u2019 (2012) respondents reported that none of their clinical providers ever discussed blood-borne transmission as a potential explanation for how infection occurred.It is unclear the extent to which blood-borne HIV risks are covered in HIV counseling in southern Africa. As I demonstrated in this article and a prior report (reference 18), public HIV education campaigns in southern Africa have not in the past and do not currently address blood-borne HIV risks, even though they are often funded and guided by large international aid agencies such as USAID, the Global Fund, PEPFAR, DFID, and UNAIDS. Therefore, it is reasonable to question how well such risks are addressed in these countries\u2019 HIV counseling programs.Any potential bias in reporting prior HIV testing by infected persons cannot account for the strong national-level inverse association between knowledge of blood-borne HIV risks and HIV infection (see reference 18). Countries in which many people are aware of such risks have much lower HIV prevalences than countries in which few people are aware of these risks.Also, potential bias in reporting prior HIV testing by infected persons is irrelevant to the association between uninfected mothers\u2019 knowledge of blood-borne HIV risks and HIV infection in their children (reported in the current article). Children of uninfected mothers who know about these risks are much less likely to be infected than children of uninfected mothers who do not know about these risks.Furthermore, even if infected persons who denied prior HIV testing were included in the data I analyzed, their inclusion could not generate the observed inverse association between knowledge of blood-borne risks and HIV infection. If they had learned about blood-borne risks during testing or clinical care, and reported such awareness in the Mozambique AIS, their responses would produce a tendency toward a positive, rather than inverse, association between knowledge of blood-borne risks and HIV infection.ReferenceClass D. The socio-political economy of antiretroviral treatment as HIV prevention . Doctoral dissertation, University of Trento, 2012. Available at http:\/\/eprints-phd.biblio.unitn.it\/803\/.","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#referee-comment-53","order":1,"name":"referee-comment-53","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.50.r100, Nigel Livesley, USAID East Africa, University Research Co., LLC, Bethesda, MD 20814, USA, 27 Jul 2012, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#referee-response-100","order":2,"name":"referee-response-100","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Devon Brewer<\/b>; \n<i>Posted: 30 Jul 2012<\/i>; I thank Dr. Livesley for his review. He claims that I cited selectively from the literature and oversimplified issues, and that my interpretation of the results and the conclusions are not supported by the data. In this reply, I demonstrate that these charges are incorrect.  Livesley states that \u201cthe preponderance of studies show that sexual exposure is by far the most common mode of HIV transmission\u201d and criticizes me for not citing three articles that he thinks support this view. However, there is no solid empirical evidence that vaginal sex is the dominant mode of HIV transmission in sub-Saharan Africa, because studies with designs rigorous enough to determine modes of transmission have not yet been conducted. In the last paragraph of the current article, I wrote \u201cto determine the modes of transmission of HIV in sub-Saharan Africa 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\u2019 HIV isolates56 57 58.\u201d My colleagues and I have published this plea dozens of times in the last nine years, and no other researchers have attempted to conduct the necessary research. Simply stating that vaginal sex is the dominant mode of transmission, or wishing it to be the case, does not make it so; rather, in science, strong empirical evidence must be presented to support a claim. My colleagues and I carried out a study in Calabar, Nigeria in which we assessed blood and sexual exposures fairly comprehensively in incident HIV cases and controls (Peters \n<i>et al.<\/i>, 2009). We found that diverse blood exposures were associated with incident HIV infection. To my knowledge, no epidemiologic study of HIV infection before or since has matched or surpassed the strength of the research design of the Calabar study. Consequently, little can be concluded about the dominant modes of HIV transmission in Africa.  Livesley cites Gisselquist D \n<i>et al.<\/i> (2004), Hauri \n<i>et al.<\/i> (2004), and White \n<i> et al.<\/i> (2007) as sources to support the hypothesis that vaginal sex is the dominant mode of HIV transmission in sub-Saharan Africa. These citations that do not provide support for this hypothesis. Gisselquist \n<i>et al.<\/i> assessed a small set of risk factors (and only one blood exposure, receipt of injections) in relation to incident HIV infection in Rwanda. As I have noted, it is not possible to determine modes of transmission with such a design, especially when blood exposures were so incompletely assessed. Hauri \n<i>et al.<\/i> and White \n<i>et al.<\/i>&nbsp; reported results from modeling exercises on the share of HIV infections that may be due to unhygienic medical injections (just one of many blood exposures encountered by Africans). I and others disagree with many of the assumptions and parameter estimates used and emphasized in their simulations (because they are at odds with empirical data). Their models also lack several key risk components of unhygienic injection practices. I refrain from a detailed technical critique of these studies here. Crucially, neither modeling exercise produced an estimate of the share of HIV transmission due to vaginal sex. Furthermore, modelers have not been able to simulate HIV epidemics that resemble African epidemics with parameter estimates derived from empirical data on Africans\u2019 vaginal sex behavior (Brewer \n<i>et al.<\/i>, 2007).  Livesley faults me for citing my prior article that showed a strong inverse association between knowledge of blood-borne HIV risks and HIV prevalence at the national level in sub-Saharan Africa (Brewer, 2011). It is unclear why this is problematic, as the result is robust, and consistent with individual-level results and historical prevention campaign experience. Livesley notes that I did not discuss other possibilities for national variation in HIV prevalence. Such variation is not the focus of my current article; instead, I focused on knowledge of HIV transmission risks in Mozambique. Nonetheless, it is worth evaluating the two sources Livesley cites, both based on the Four Cities Study, for other explanations of variation in HIV prevalence across Africa. The Four Cities Study did not involve assessing participants\u2019 blood exposures. Perhaps even more importantly, the results from the Four Cities Study showed that putative sexual risk factors (such as sex partner concurrency and other high risk sexual behaviors) were inversely associated (in the case of concurrency) or not associated with HIV prevalence in the four cities (Auvert \n<i>et al.<\/i>, 2001; Lagarde \n<i>et al<\/i>. 2001; Rothenberg \n<i>et al<\/i>., 2002).  In my F1000Research article, I stated that there is a \u201clack of association between condom use in vaginal sex and incident HIV infection14 52 53\u2033 (p. 5) and cited three articles on studies conducted in sub-Saharan Africa (the only three I was aware of at the time that reported on the association or lack thereof). These three articles showed inconsistent results (Feldblum \n<i>et al<\/i>., 2010: positive association; Wawer \n<i>et al<\/i>., 2005: no apparent association; Allen\n<i> et al.<\/i>, 2003: inverse association), which I summarized as a lack of association. Livesley cites Weller and Davis-Beaty 2007 for the hypothesis that condoms protect against HIV transmission during vaginal sex. However, Weller and Davis-Beaty\u2019s summary included studies from regions outside of Africa, did not account for confounding of condom use with other risk factors (such as common blood exposures in Africa), and did not include Feldblum \n<i>et al.<\/i> and Wawer \n<i>et al.<\/i>&nbsp; results. About half of the studies in Weller and Davis-Beaty\u2019s summary were based on condom use measures that applied to anal sex as well as vaginal sex. Consequently, Weller \n<i>et al<\/i>. results cannot be used as an estimate of the protective effect of condom use during vaginal sex in sub-Saharan Africa or elsewhere. The protective effect of condom use during anal sex, though, has been well-established in other research.  Livesley questions my description of adjusted odds ratios of 0.81 to 0.95 for the association between knowledge of blood-borne HIV risks and prevalent HIV infection as indicating an inverse relationship. By definition, odds ratios under 1.0 reflect inverse or negative relationships. The adjusted odds ratios were in the inverse direction for two different measures of knowledge of blood-borne HIV risks and for both women and men. The confidence intervals for these odds ratios do include 1.0. However, the consistency of the association across measures and sample subgroups, and similarity in magnitude of the association to similar associations in neighboring and nearby countries mean that it is warranted to describe the relationship as inverse.  Livesley criticizes me for characterizing the adjusted odds ratios between knowledge of anal sex and HIV infection in women (AOR = 1.18) and knowledge of vaginal sex and HIV infection in men (AOR = 1.85) as \u201cmeaningfully positive.\u201d In this context, I intended \u201cmeaningfully positive\u201d to refer to associations that were mild to moderate in magnitude. Livesley also correctly noted that \u201cthe OR for men\u2019s understanding of vaginal sex is close to being statistically significant.\u201d This result means that Mozambican men who believed that HIV can be transmitted through vaginal sex without a condom were twice as likely to be infected with HIV as men who did not believe vaginal sex was a risk.  Livesley argues that the results in my article do not suggest that HIV education programs in sub-Saharan Africa should include a focus on blood-borne risks and anal sex. The results show that Mozambican adults who were unaware of blood-borne transmission were at increased risk for HIV infection, and that children of uninfected mothers who were unaware of blood-borne transmission were at much increased risk for HIV infection. Almost half of Mozambican adults did not know anal sex was an HIV transmission risk. In my opinion, these findings justify including a focus on blood-borne risks and anal sex in HIV education efforts. Livesley further wonders how such topics could be incorporated in HIV prevention and education programming. Successful examples abound. As I discussed in my 2011 article, there is a \u201cheavy emphasis on avoiding blood-borne risks in HIV education programs for primary school students in rich countries [69,70], travelers to poor (especially African) countries [71-73], and employees of the United Nations working in poor countries [74,75]\u201d (p. 194). Most of these educational efforts have been standard and ongoing for over two decades. The risk of anal sex has also been continuously emphasized in HIV prevention and education programs in rich countries. Moreover, during the last 30 years, there have been many instances of HIV education campaigns highlighting blood-borne risks in west and central Africa (Brewer, 2011), although it is uncertain how widespread and consistent these efforts have been. These examples show that people can be more fully informed of the range of HIV risks without additional program cost.  The fundamental question is moral and ethical. On what grounds can HIV prevention and education programs in Africa, funded by taxpayers and sponsored by international agencies, foreign aid agencies, and national governments, continue to deprive people of highly relevant, life-saving information?","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#referee-comment-50","order":3,"name":"referee-comment-50","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.50.r101, Carlos Morel, FIOCRUZ\/CDTS, Oswaldo Cruz Foundation, Ministry of Health, Rio de Janeiro, Brazil, 02 Aug 2012, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#referee-response-101","order":4,"name":"referee-response-101","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Devon Brewer<\/b>; \n<i>Posted: 02 Aug 2012<\/i>; I thank Dr. Morel for his review. I computed the adjusted odds ratios with multiple logistic regression. If there are any other points that require more information, I hope reviewers and readers will highlight those sections, so I can clarify them.","URL":"https:\/\/f1000research.com\/articles\/1-1\/v1#referee-comment-52","order":5,"name":"referee-comment-52","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":6,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Data associated with the article are available under the terms of the Creative Commons Zero \"No rights reserved\" data waiver (CC0 1.0 Public domain dedication).","order":0,"name":"copyright-info","label":"Copyright"}]}}