Bloodborne HIV: Don't Get Stuck!

Have you heard of people in your community with unexplained HIV infections – children with HIV-negative mothers, virgin youth, spouses with one lifetime HIV-negative partner? In countries outside sub-Sahara Africa, communities and governments have investigated unexplained infections to find and fix the source. This has not happened in Africa.

African governments ignore unexplained HIV infections

Over more than 30 years, people in Africa have recognized hundreds of thousands — maybe millions — of unexplained infections in their families and communities. No community or government has investigated by testing widely to find all victims and thereby to zero in on and fix dangerous skin-piercing procedures. Click on country pagers for an account of some reported unexplained infections (countries in alphabetical order): Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo (Brazzaville), Cote d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, South Sudan, Swaziland, Tanzania, Togo, Uganda, Zambia, Zimbabwe.

How do investigations stop bloodborne transmission?

Outbreak investigations in countries outside sub-Saharan Africa have revealed doctors and nurses being careless and cutting corners, for example, changing needles but reusing syringes for injections, or reusing plastic tubes or saline bags for infusions. Healthcare staff, even those not involved in an investigated outbreak, may realize that procedures they thought were safe enough were not, and may have infected patients. Investigations remind healthcare staff to practice what they have learned, to follow “standard precautions”[1] to protect patients.

Investigations may have their biggest impact for safety by alerting the public to skin-piercing risks. People can see and avoid some bloodborne risks. Patients’ fears encourage (push) healthcare providers to be more open about risks and about how they sterilize reused instruments.

No fault investigations?

Keeping the focus on preventing future infections, the primary goal of investigations should be to find and fix errors, not to punish perpetrators or compensate victims. Investigations that look for and find many or most people who have been infected in an outbreak can work backward from who was infected to pinpoint the facilities, procedures, and specific errors that allowed HIV to go from one patient or client to another. People found to be infected can be treated.

Speed saves lives. Finding all (or at least most) people who have been infected in an outbreak as fast as possible requires the cooperation of doctors and nurses, including those who infected patients through carelessness or ignorance but without any intent to harm. If such doctors and nurses are threatened with prison or financial ruin, they could be expected to obstruct investigations, thereby making it harder to find and treat victims and to find and fix mistakes.

Given the likely scale of HIV infection from health care over many years in sub-Saharan Africa, even multiple investigations could be expected to identify only a small fraction of healthcare staff who accidentally and carelessly infected patients. Prosecutions would, in practice, be arbitrary, going after whoever happens to be unlucky or powerless, especially low-income front-line staff, but missing managers and senior ministry officials who saw and accepted risks and unexplained HIV infections for decades.

Similarly, given the likely scale of HIV transmission through unsafe health care over many years, even multiple investigations could be expected to find no more than a small fraction of victims. But even a small fraction would be too large for anyone – even government – to compensate except by offering free HIV care, which is already available to most if not all Africans with HIV from any risk.

Since justice would not be achieved by selective prosecutions, no-fault investigations arguably promise the best justice available. No-fault investigations could be understood as a component of restorative justice,[2] helping healthcare workers recognize and admit what they have done, reducing harms from future health care, and finding and caring for victims.

References

1. International Society for Infectious Diseases (ISID). Guide to Infection Control in the Healthcare Setting. ISID [internet], 2019. Available at: https://isid.org/guide/ (accessed 19 September 2020).

2. Gabagambi JJ. A comparative analysis of restorative justice practices in Africa. Hauser Global Law School Programme [internet], October 2018. Available at: https://www.nyulawglobal.org/globalex/Restorative_Justice_Africa.html (accessed 3 September 2020).