Bloodborne HIV: Don't Get Stuck!

One of the remarks that many articles about the Cambodian HIV outbreak are mentioning now, almost as if every journalist is tweaking the same press release and putting their name on it, is about needlestick injuries and the CDC’s estimate that “99.7% of needlestick occurrences involving HIV infected blood do not result in transmission“.

This figure is irrelevant and entirely misleading: receiving an injection or an infusion is nothing like a needlestick injury when some or all of the equipment, or the substance being administered, are contaminated. Needlestick injuries are typically slight and shallow and the inoculant is likely to be very small.

Some of the titles also mention ‘tainted needles‘, but this may give the incorrect impression that reused syringes are not also a likely factor in this outbreak, along with contaminated multi-dose vials of medicines, vaccines, distilled water and other substances.

An injection involves the needle going below the skin, into muscle or into a vein, depending on what kind of injection it is. Most of the contents of the syringe and needle, along with anything remaining in them from previous uses, goes into the patient’s body. Some estimates of risks are given on this Don’t Get Stuck With HIV webpage.

Most of the contents of the syringe and needle enter the patient’s body. Some remains in the syringe and needle. In addition, it is possible for a vacuum to form in the syringe, allowing a small amount of blood from the patient to enter the syringe. To repeat, this is nothing like a needlestick injury.

Someone from the World Health Organization is reported as saying “different types of injection procedures carry different levels of risk“, which is a major improvement on the CDC quotes, but the WHO remark needs to be explained further, while the CDC one needs to be removed altogether.

Similar remarks apply to infusions, intravenous drips, etc. The risk of transmission from some common procedures can be very high indeed. Visitors to Cambodia may have noticed how popular intravenous drips are, with passengers on the back of motorbike taxis holding up the bag as they ride, and small ‘medical’ practices opening on to streets in Phnom Penh (although I doubt if many visitors have used such clinics because they tend to be aware of the risks of infection with HIV and other viruses through unsafe healthcare).

It is also very disturbing that the single practitioner said to have been involved in the outbreak has been arrested, imprisoned and even accused of murder (though little mention has been made of any murder victims). This is not going to encourage other practitioners, or professionals of any kind, political, administrative, ancillary, etc, to come forward and assist with the inquiry.

Members of the public may be careful what they say to police if they think others may be arrested and accused of murder. But even employees of CDC, WHO, UNAIDS and the like may be reluctant to find evidence that the risk of healthcare associated HIV transmission is very high, because they have been insisting for several decades that it hardly ever occurs.

To ensure the cooperation of as many health practitioners as possible the Cambodian authorities need to consider a ‘no blame’ investigation. Every article so far suggests confusion, professionals not recognizing HIV risks from unsafe healthcare, politicians appearing to know nothing about it and, more importantly, members of the public not knowing about the risks they face, or how to avoid them (there is some useful advice here).

It is especially important that members of the public are involved and that they understand a ‘no blame’ investigation. While some people may be angry about the single unlicensed practitioner identified so far, the entire health service, department of health, and even the global health community must share some of the responsibility.

Local human rights NGO Licadho stresses this point. The government of Cambodia (and governments of every developing country) have been claiming to have implemented ‘universal precautions’ to prevent healthcare associated HIV transmission. But is this a mere tick in a box marked ‘universal precautions’?

In the light of this and numerous other outbreaks, declarations about universal precautions may need to be questioned to establish if there is any mechanism for ensuring that these precautions are being followed, and even if it is possible to follow them in seriously under-resourced health services.

There has been a lot of wringing of hands and gnashing of teeth among the global health community about how the recent ebola epidemics in Guinea, Liberia and Sierra Leone may have been contained if only there had been universal healthcare (UHC) in place. Amartya Sen even makes a similar point in his excellent article on UHC in the English Guardian.

But this public angst seems to imply that around 20 earlier outbreaks of ebola were contained because health systems in the countries involved, Nigeria, Uganda, Sudan and the Democratic Republic of the Congo, were adequate. In fact, the opposite was the case in some instances, with several outbreaks dying out once the local healthcare facilities were overwhelmed and forced to close down.

Perhaps UHC, however vital, is not enough on its own? For the seven countries listed above, can anyone say that health services, while weak, are safe? An article just published on knowledge and practice of universal precautions among healthcare workers in Nigeria concludes that “the practice of universal precaution is not given much attention in [Primary Health Care] and this may constitute health risk to the nurses and the patients in the study setting“.

Nigeria is not alone; the Don’t Get Stuck With HIV site’s ‘Cases of HIV from Blood Risks’ section lists 17 African countries where healthcare related outbreaks have occurred, along with nine non-African countries. Cambodia will soon be added to the latter collection.

The number of people found to have been infected with HIV in Roka Commune, Battambang Province, probably through unsafe healthcare, possibly administered by an unlicensed practitioner, is now well over 230. But that number is already several days old.

More importantly, the inquiry appeared to go beyond the village where the first cases were found, as more turned up from other villages. Will the inquiry also look for outbreaks elsewhere around the country? Surely there are other unlicensed practitioners, other practices where safety is not the priority it should be?

In addition, there may be licensed practitioners and practices where risks are being taken. Perhaps few people have been infected as a result, perhaps none; but if unsafe practices are to be found anywhere in the country there is a risk that there will be other outbreaks in the future.

There have been no serious investigations of healthcare associated HIV outbreaks in African countries, where all the worst epidemics are to be found. The countries where there have been investigations are mostly ones where the global health community does not have a lot of influence, such as China, Kazakhstan, Uzbekistan and Kyrgyzstan.

An investigation carried out in 2008 in Pakistan after a very large number of people tested positive in this low prevalence country was too superficial to identify any additional infections, although the outbreak was clearly a result of unsafe healthcare. Here too, the finger was pointed at a few unlicensed practitioners, leaving licensed healthcare out of the picture altogether.

None of the media reports from Cambodia suggest that journalists are making any attempt to go beyond what they are fed in the form of press releases. They could quite easily ask people in any village in the country, or even in the cities, about unlicenced practitioners and practices. But the implications of this outbreak seems to be entirely lost on them.

The Australian media, in particular, has had little to add to the subject, although Cambodia is dominated by Australian NGOs, NGO workers, expats of various kinds, business people, tourists and the like. Australians are less likely to visit unlicensed practitioners or practices, but levels of safety in licensed healthcare are unknown.

The UN and its employees are not in any danger, of course, because they are all issued with advice, even injecting and other equipment when they visit certain areas. They have their own UN-approved health facilities and would rarely any serious healthcare risks.

The press may continue to wait for the scraps that will eventually be thrown to them, or they could carry out their own investigation into healthcare safety in the light of the outbreak of healthcare associated HIV in Battambang Province. But they may end up missing a cover-up on the same scale as the one that appears to have gone unnoticed by the press in Pakistan a few years ago.

If there was an injectible birth control method that doubled the risk of HIV positive people using it infecting their partner, and also doubled the risk that HIV negative people using it would be infected themselves (if their partner is infected), you’d expect the WHO to issue a warning, right?

But Depo-Provera (DMPA) is widely marketed by NGOs and other institutions running family planning programs in developing countries, and WHO (World Health Organization) evidently believes that reducing births is more important than safety.

This is great for Pfizer, and now, thanks to their new symbiotic relationship, it’s great for Gilead too, because women using Depo-Provera may be able to reduce their risk of being infected, or of infecting their partner. All they have to do is take drugs kindly produced by Gilead, in the form of pre-exposure prophylaxis (the use of antiretroviral drugs, either daily or intermittently, to reduce the risk of infection with HIV).

You might think that this would not happen, that surely, Depo-Provera would be taken off the market, or at least carry a warning. But companies such as Pfizer and Gilead have been very successful in getting institutions like the WHO, along with various universities and donors (such as those listed in the AIDS Journal article), to help them market their products.

PrEP is something of a solution in search of a problem. It is possible that HIV negative people who wish to have unprotected sex with HIV positive people (or people whose status is unknown) would be able to reduce their risk of being infected. But the majority of people in African countries are probably not in this position; PrEP is likely to be more of a recreational drug for wealthy countries.

If people wish to reduce their risk of being infected with HIV (or of infecting others) they would be well advised to avoid Depo-Provera. There are plenty of other birth control methods, some of which also protect against HIV and various sexually transmitted infections.

The problem is that HIV positive people using Depo-Provera and HIV negative people whose partners use it are not being warned about these well documented risks. They are not suffering from a lack of pre-exposure prophylaxis, but they might be suffering from poor, incomplete or biased family planning advice.

There are industry sponsored trolls on social media sites, Twitter for example, who pounce on anyone who tries to question the safety of Depo-Provera. But the above AIDS Journal article seems to confirm what critics have been saying, while at the same time offering another patented solution that can be taken in conjunction with the discredited birth control method.

In contrast to PrEP, Depo-Provera seems to be almost exclusively marketed to poor people in rich countries and to anyone and everyone in poor countries. No conflict of interest is declared in the peer-reviewed journal that published the paper, and the donors listed are all well known and highly influential, particularly in relation to Depo-Provera studies.

According to an article in the UN’s IRIN News “West Africa’s Ebola epidemic has cruelly exposed the weaknesses of health systems in the countries where it struck”. The director of the World Health Organization, Margaret Chan, is further quoted as saying that “what they lacked was a robust public health infrastructure to deal with the unexpected”.

This is a very odd way of looking at the situation. Firstly, almost every country in Africa lacks a robust public health infrastructure; secondly, most of them have lacked such an infrastructure for many decades, as a cursory review of relevant literature, going back at least to the 1940s, will reveal.

Tens of millions of people suffer from numerous avoidable health problems, such as malnutrition, vitamin deficiencies, parasitic conditions, infectious diseases, non-communicable diseases and more; epidemics and outbreaks are so common that most of them don’t even hit the headlines, least of all the headlines of non-African newspapers.

Not only that, but this has been the case throughout the whole of the WHO’s history. Lack of health infrastructure to deal with the ‘unexpected’ has been the norm in sub-Saharan Africa for decades, as the WHO (as an institution) can confirm. They were involved in various campaigns to reduce or even eliminate some health conditions, sometimes successfully, sometimes not so successfully.

In fact, many of their less successful forays into eliminating or eradicating diseases demonstrated that it is not possible to ensure that diseases can even be eliminated from large areas without adequate health infrastructure, let alone eradicated. Various programs to reduce prevalence of certain sexually transmitted infections were unsuccessful precisely because of failures relating to overall health infrastructures, rather than to any weaknesses in the programs concerned.

The HIV epidemic has raged in many sub-Saharan African countries regardless of various expensive and well publicized programs to reduce transmission. Some country epidemics have declined, but many did so before the bulk of prevention campaigns were even dreamed up; in other countries there are few credible causal links between HIV prevention programs and drops in transmission rates.

Chan would be better off asking why the ongoing ebola epidemics in West Africa are so much worse than any that have occurred elsewhere. It would also be interesting to know why HIV epidemics in West African countries were so much less severe than in African countries that are said to have far better developed health systems than Sierra Leone, Guinea and Liberia, such as South Africa and Botswana.

Chan goes on to bemoan lack of “background data on the usual…so that the unusual stands out”. I’ve been reading articles about sexually transmitted infections in African countries published between the 1940s and the 1990s. Most of them attest to the lack of reliable information and statistics. ‘The usual’ is what you find in the three countries who have suffered the most in the current epidemic: health systems in most other African countries are in a similar state.

Decades of epidemics have, apparently, yet to teach us that you are unlikely to be able to mount a successful campaign against disease outbreaks if you don’t have well developed health infrastructures. You can’t hurriedly put everything together in a package and send it off with some soldiers, so they can piece it together before heading off to their next dig a hole and fill it in scheme.

Chan is right in demanding “good quality care [that is] accessible and affordable to everyone, and not just to wealthy people living in urban areas; having enough facilities available in the right places with enough well trained staff and uninterrupted supplies of essential medicines; diagnostic capacity that returns rapid and reliable results; and information systems that pinpoint gaps and direct strategies and resources towards unmet needs”.

But she should start by taking a close look at those villages in Cambodia where several hundred people have been infected with HIV through unsafe healthcare. There is little point in developing health infrastructures without ensuring that they are also safe. Otherwise, she may end up with another Egypt on her hands, which has the highest prevalence of hepatitis C virus in the world following an otherwise successful schistosomiasis eradication campaign.

The ongoing inquiry into an outbreak of HIV in several Cambodian villages has so far found more than 160 cases. Most cases were found in one village, but 20 were found in a nearby village and a few more in a third.

However, the inquiry needs to be expanded to include all villages where such an outbreak may have occurred. It also needs to be expanded beyond unlicensed premises and practitioners. It should include all health facilities, pharmacies, practices and anywhere skin piercing procedures take place.

The reason the inquiry needs to be so broad is that anyone in the country may be as ignorant as their esteemed leader, Hun Sen, about the risk of being infected with HIV through unsafe healthcare. Many people may only have heard about sexual risk; those who have heard about non-sexual risks have probably heard that it is very unlikely, which is the received view propagated by UNAIDS, WHO, CDC and the like.

Also, the CDC estimates for the risk of being infected through reused injecting equipment seem unbelievably low. They claim that the risk from needle-sharing during injection drug use is 63 in 10,000. The one unlicensed practitioner arrested so far has admitted to reusing syringes and needles, so the risk may be similar to that faced by injection drug users. But compare those CDC figures to estimates on the Don’t Get Stuck With HIV site.

If the risk is as low as CDC’s 63 in 10,000 then this single unlicensed practitioner must have an impossibly large number of clients, who receive a lot of treatment that involves skin piercing of some kind. It is far more likely that other practitioners, licensed and unlicensed, also take risks. Yet, infections will only be brought to light if the investigation is broad and thorough enough.

The investigation also needs to report honestly. Hun Sen may wish to protect his country’s image of one that has avoided a very serious HIV epidemic; UNAIDS may wish to continue denying non-sexual transmission through unsafe healthcare; CDC may not want to review their estimated risk, for whatever reasons, etc.

But the most important thing is to discover how people have been infected, then cut off these routes to infection. This kind of outbreak could happen again and again, because neither practitioners nor members of the public are being warned of the risks of infection through reused medical instruments and other unsafe practices.

The investigation so far has demonstrated one of the dangers of the sort of culture of blame that has been developed by UNAIDS and the HIV industry. If those found to be engaged in unsafe practices are persecuted, threatened, imprisoned or otherwise punished, the investigation is unlikely to bring too many outbreaks and unsafe practices to light.

Those already infected need to be identified, and given treatment and support. Those at risk, likely to be a very large number of people, need to be proteted from harm.

The arrest of a single practitioner to date looks like a case of scapegoating, somewhat resembling Libya’s reaction when an outbreak was discovered there, or the Ugandan nurse sentenced to several years in prison for ‘negligence’ because she is said to have risked infecting an infant with HIV (she was released after serving nearly one year but the conviction was upheld).

Condemnation of those engaging in unsafe practices, when the HIV industry itself has failed to warn practitioners and patients about the risks, is entirely misplaced. It only adds to a systematic failure to protect people from being infected, as well as exposing health practitioners and others to abuse and accusations of ‘deliberate’ transmission of HIV.

On 16 December, newspapers reported more than 80 residents of a Cambodian village had tested HIV-positive in recent weeks. As of 20 December the reported number testing positive reached 140. Testing is continuing, so that number will likely increase further.

“The crisis began in late November, when a 74-year-old man from Roka tested positive for HIV at the Roka Health Center, according to a statement from Cambodia’s Ministry of Health and the World Health Organization. After receiving the result, the man then sent his granddaughter and son-in-law for testing. They also tested positive for the virus. The man then informed other villagers who had been treated by [an unregistered doctor] to get tested for HIV. After that, the number of cases steadily rose” (quote from: http://www.wsj.com/articles/worries-mount-that-hiv-infections-in-cambodian-village-could-rise-1419062070).

Outbreaks such as this are not unusual (see: http://dontgetstuck.org/cases-unexpected-hiv-infections/). What is unusual is that this one is recognized. It will be even more unusual if it is thoroughly investigated and reported.

An investigation can limit health damage.
1. Limit damage to the victims. Test widely to find as many victims as possible. Then ensure they get good treatment so they can look forward to a near-normal life.
2. Limit damage to others. Investigate to find the specific risks so they can be stopped, not only in this village but in thousands of similar situations in Asia and Africa. Did HIV go through saline infusions, intra-muscular injections, vaccinations, what? When the routes are identified in this outbreak, tell the public at risk in Cambodia and elsewhere so they can help to develop responses to protect themselves and others.

These two challenges can be satisfied with a no-fault investigation. The investigation could be modeled on a truth commission. People who might have been involved in transmission can be asked to cooperate – to report (confess) procedures that might have been unsafe and to report who they treated – in return for a promise not to prosecute.

What can be distracting in an investigation are efforts to pin the blame on one or more people, to put them in prison or sue them. Fear closes doors – what we need are open doors to find what went wrong and fix it. Yes, there is a lot of careless behavior in clinics and hospital – but many who are careless do not realize the risks because they have been confused by lies, eg, that HIV dies in seconds outside the body.

If careless people are to be prosecuted, should we start at the top? Leaders of the health aid industry know health care is often unsafe in much of Asia and Africa and yet support the delivery of invasive procedures without warning the public and without insisting on outbreak investigations to find and stop careless errors. Since it’s unlikely anyone will try to prosecute people at the top, let’s not scapegoat people at the bottom for careless behavior.

A good example of a failed investigation is what happened in Jalalpur Jattan, Pakistan, six years ago (see: http://dontgetstuck.org/pakistan-cases-and-investigations/). In 2008, a local NGO tested 246 people in the community, finding 88 to be infected. This got the attention of Pakistan’s National Institute of Health, which assigned Pakistan’s Field Epidemiology & Laboratory Training Program (FELTP) to investigate, with assistance from the US Centers for Disease Control and Prevention (CDC). The Government charged FELTP to: “determine the extent and chain of transmission” and to “identify…sites of potential transmission.”

FELPT’s investigators did neither. They began with a list of 20 HIV-positive people provided by the government hospital, traced relatives, and looked for people with stigmatized behaviors (sex work, male-male sex, injection drug use). Because the “investigation” did not test the general population it could not determine the extent of transmission or sites of transmission. The report added insult to injury with stigmatizing sexual fantasies: “there may be hidden extramarital and unsafe sexual practices in the community which were difficult to unveil” (see p 51 in: https://bloodbornehiv.com/wp-content/uploads/2012/02/feltp-investigation.pdf).

In Cambodia, let’s hope for an investigation that prioritizes finding and caring for victims (see: https://en-maktoob.news.yahoo.com/families-devastated-cambodia-hiv-outbreak-100523638.html) and preventing more victims – and that does not insult victims with accusations of stigmatized behaviors.

Prime Minister Hun Sen of Cambodia is probably not the only national leader totally confused about HIV/AIDS. The news that over 100 people may have been infected with HIV as a result of an “unlicensed” doctor reusing skin piercing equipment, such as syringes, needles, intravenous drips and possibly others, underlined the leader’s complete ignorance about HIV transmission.

The prime ministers first response was to doubt if the HIV tests were accurate. But he seems to believe that HIV is exclusively transmitted through sex (and perhaps from mother to child or through injecting drug use). He doesn’t seem aware of transmission through blood exposure as a result of unsafe health, cosmetic or traditional practices. He also seems to believe that the quack arrested for performing these unsafe procedures must himself have been infected with HIV, which is not the case.

If one of the quack’s patients was HIV positive, reusing equipment that pierces the skin, or even is inserted into the mouth or other orifices, runs the risk of transmitting HIV and various other pathogens.

It wasn’t that long ago that Cambodia was predicted to be the first country to eliminate HIV transmission altogether, perhaps in the next few years. The epidemic is very small there and most transmission is likely to be through male to male sex and intravenous drug use.

But the outbreak in Roka Commune, Battambang Province shows that there are other risks. This kind of outbreak is likely to have happened many times in many countries over the past few decades. What makes this outbreak different is that it was noticed and (hopefully) investigated. Many quacks, perhaps even legitimate healthcare practitioners, may be reusing equipment, completely unaware that this could be exposing their patients to HIV, hepatitis and other bloodborne diseases.

A survey in Kenya and several other African countries found that people who have had injections in the past 12 months are far more likely to be HIV positive than those who have not. Babies in Mozambique and Swaziland have been found to be infected with HIV even though their mothers are negative (or the mothers have been infected by their babies). Women who only have sex with other women, which is extremely low risk, have been infected.

But in African countries this kind of outbreak remains uninvestigated. The women in Mozambique have never been told how their babies may have been infected, and have been allowed to believe that it was their (the mother’s) fault. The women who have sex only with other women have been told that such sexual behavior must be, after all, risky. And the many people who have probably been infected through unsafe healthcare have never been given any explanation.

So it’s not surprising that PM Hun Sen doesn’t believe the results: he, like most people in most countries, rarely hear anything about non-sexual transmission of HIV, through unsafe healthcare, cosmetic and traditional practices. This is in a country where healthcare conditions are poor and a lot of people resort to self medication, quacks or other people with few or no healthcare skills.

Hun Sen asks if an 80 year old person or a child are likely to be infected with HIV; and the answer is yes, anyone can be infected through any skin piercing practice where the equipment is reused and conditions are unsterile. They are also likely to be infected with hepatitis and any other bloodborne pathogen that is going around. Hospitals, dental surgeries, tattoo parlors, hairdressers and many other settings may be similarly risky.

So it’s time for UNAIDS and the WHO to come clean, because if national leaders are so confused about HIV modes of transmission, how clear can members of the public be? If we are constantly bombarded with misleading statements about sexual risks, but rarely told about serious non-sexual risks, everyone could be as confused as the Cambodian Prime Minister.