Bloodborne HIV: Don't Get Stuck!

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Extent of Unsafe Medical Injections in Resource Poor Settings Unknown

Although it is written in a somewhat anecdotal style, a recent article by Moses Okinyi raises some important points. Estimates of the relative contribution of unsafe medical injections to HIV epidemics in African countries range from the improbably low of less than 1% to the frighteningly high 25%. But what is most shocking is that there are only estimates, based on far too little data. This is an unacceptable situation thirty years into the HIV pandemic.

Okinyi notes the use of figures for HIV infections in children who have HIV negative mothers to build up some idea of the size of the problem. But many may be horrified just to hear that there are sizable numbers of HIV positive children with HIV negative mothers, the children’s HIV positive status often not being identified until years after they were infected because their mother happened to test negative.

The recently released film, Puncture, touches on some of the issues. A nurse is infected with HIV through a needlestick injury when working with a HIV positive patient. Things get interesting when the ensuing investigation reveals that there are syringes available that reduce the chances of such an injury and eliminate reuse of the device. Yet rivalry between producers of medical devices meant that the hospital was still using disposable syringes which carry a risk to the healthcare workers, and can also be reused.

Of course, the fact that syringes can be reused doesn’t mean that they are reused. But in countries where HIV prevalence is high and resources are scarce, it could be a temptation, even a necessity. Several Service Provision Assessment Reports have shown that many health facilities don’t have the equipment, supplies, procedures, even the training they need to prevent infection in healthcare settings.

The movie apparently (I haven’t seen it) takes an adversarial approach to the issue. This is unlikely to be helpful in developing countries, where eliminating such infections is the most important step, rather than pointing fingers at those thought to be ‘to blame’. There has been too much finger pointing already and it has been counterproductive.

However, people in high prevalence countries need to know how to avoid being infected with HIV and other blood borne diseases in healthcare and other settings, how to avoid transmitting these diseases and generally ensuring that the healthcare they and their family and friends receive is safe.

In addition to avoiding infection, recognition that HIV is not always transmitted sexually should reduce the stigma which has built up around a disease that is said by UNAIDS and the HIV industry to be 80-90% transmitted by unsafe heterosexual sex. In fact, the industry doesn’t really know the extent of non-sexual HIV transmission, despite their glib assurances.

Okinyi mentions a young HIV postive boy in Kenya who was probably infected through contaminated injecting equipment, or some other medical device. The boy’s mother is still HIV negative, though she would have risked being infected by her child through breastfeeding. It was only when the boy was diagnosed with TB that he was even tested for HIV. If his mother had been tested then and been found to be positive, it is likely that the whole issue of hospital transmitted HIV would never have been raised.

A lot of effort has been made to replace reusable syringes in resource poor countries but there is still a long way to go. And it’s not in the interest of those producing reusable (though nominally disposable) injecting equipment to advocate the use of something that is made by a competitor. Producers of medical devices, like pharmaceutical companies, make good use of their ability to influence what products doctors and other practitioners use most. Patient safety is only going to be a concern to them if it guarantees they increase their profits. If it cuts into their profits, they might prefer the issues to remain ignored (or strongly denied, as they are by UNAIDS).

Using estimates of HIV inefections in infants and young children tends to rule out the possiblity that they were infected sexually. Whereas, if any HIV positive person in high prevalence African countries is, or could be sexually active, it is generally assumed that they were infected sexually, regardless of the low levels of sexual risk they may have faced, or the high levels of non-sexual risk.

Whatever technologies may be available, ultimately the problems of hospital acquired and hospital transmitted HIV will continue until they are recognized as problems, rather than strenuously denied. This requires thorough investigation of conditions and practices in health facilities, with honest disclosure of findings. It will then be possible to estimate the relative contributions of sexual and non-sexual modes of transmission, and implement HIV prevention programs accordingly.

Allowing unsafe healthcare practices to continue, uninvestigated, would not be acceptable in Western countries. Nor would the use of substandard equipment and supplies that are known to increase risk to patients, healthcare workers and even the environment. So why are they acceptable to Western donors, who often contribute to such phenomena through providing the health aid money, and also deciding how it should be spent?

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