Bloodborne HIV: Don't Get Stuck!

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Outbreak investigations: Facing and fixing problems

If a hospital or clinic infects you or your child with HIV, you’d probably call it a disaster. Health care bureaucrats and managers call it an “adverse event.”  How often do patients get HIV from health care in Africa? The World Health Organization (WHO) has estimated it happens 50,000-100,000 times each year.  Other estimates are higher.

That’s a lot of “adverse events.” In more than 25 years, no international agency, no donor health aid program, and no African government has done the right thing to stop them.

When a department of health finds one or several unexplained HIV infections in patients that can be traced to a suspected hospital or clinic, the recommended “textbook” response is to investigate — to invite others who attended the same facility to come for tests to see how many, if any, others are infected. By finding others infected in the same outbreak, an investigation can pin-point the errors that did the damage. This alerts health care workers to fix things they didn’t know were problems, and warns patients to demand safe care. In this way, investigations save lives.

Consider the response to “adverse events” in other countries. For example, although the US health care system is not the best or safest in the world by a long shot, US state and federal governments have been doing the right thing in response to unexplained infections of hepatitis B and C virus. In health care settings, these viruses transmit just like HIV – from patient-to-patient through blood-to-blood contact when doctors and nurses reuse instruments without sterilization.

In 10 years from 1998 through 2008, the US Centers for Disease Control (CDC) recorded 33 investigations of hepatitis B and/or C transmission through health care in clinics, nursing homes, etc. Each investigation tested from 4 to >12,000 patients. The 33 investigations found a total of 448 hepatitis B and C infections from health care (average of 13 infections per outbreak). During the next 3 years, 2008-11, 32 investigations (including 3 from the previous list plus 29 new ones) invited a total of more than 90,000 patients to come for tests and identified a total of 217 infections (average of 7 per outbreak).

Did these investigations scare people to stay away from health care? Maybe some people got scared. But the real impact goes the other way: The fact that government is alert to investigate unexplained infections assures the public that someone is watching.

Consider the alternative – what happens when there are no investigations? Not investigating unexplained infections is like smelling smoke, ignoring it, and letting the house burn down. Or yelling at your dog to be quiet when she barks at night – and waking up to find your motorcycle missing.

Aside from a few HIV infections traced to blood transfusions, there have been no investigations of any of the thousands of recognized HIV “adverse events” in Africa. During 1991-93, for example, a WHO study in Rwanda, Tanzania, Uganda, and Zambia identified 61 children aged 6-60 months who were HIV-positive with HIV-negative mothers. There is no report of any investigation in any of the four countries to find the source of these unexplained infections. Incredibly, the WHO study team concluded “The risk of nosocomial [hospital-acquired]…HIV infection appears low among these populations.”

Ideally, foreign experts and agencies would be at the forefront to help with investigations. That has not happened.

Lack of interest on the part of international agencies and donors leaves African governments with the task. Which government will take the lead to begin to investigate unexplained HIV infections? Investigations are not expensive in monetary terms – but they may ruffle feathers. Someone has to push — to persuade health care bureaucrats to recognize and investigate HIV “adverse events.”

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