Bloodborne HIV: Don't Get Stuck!

A long history of unsafe health care

During the 20th century and continuing, millions of Africans have gotten blood-borne infections, including tetanus, hepatitis B, hepatitis C, HIV, and Ebola, from unsafe healthcare. With some exceptions, the health aid community’s response has been to deny that health care accounts for more than minorities of blood-borne infections. Instead of fixing unsafe procedures, the health aid community’s repeated response has been to promote solutions involving more invasive procedures.

For example, women and infants in Africa were observed to get tetanus infections from unsterile and contaminated instruments and conditions during childbirth. The health aid community responded with tetanus vaccinations – arranging for young women to get as many as five more injections, and for babies to be injected at birth. Vaccinations protect mothers and babies from tetanus, but because additional injections are not reliably sterile, an unknown number get other blood-borne infections.

Across much of Africa in the late 20th century, 70%-95% of adults had been infected with hepatitis B at some time in their lives, while 7%-15% had continuing (chronic) infections. Most chronic infections came from exposures during infancy or early childhood. Studies in Africa reported as many as 50% of children infected before their 5th birthday. The health aid community denied an important role for unsterile health care. Instead of making sure children received safe care, the health aid community introduced another injected vaccine to protect them from hepatitis B. Vaccinations currently protect many Africans from hepatitis B but increase their risk for other blood-borne infections.

Enter HIV. Recent mainstream research traces the origin of the world’s HIV epidemic to colonial health care programs spreading a rare HIV infection (from an otherwise self-limiting outbreak, likely beginning from a chimp butchered for bush meat) to thousands of Africans through unsterile injections for sleeping sickness, yaws, and suspected sexual infections. A lot of evidence suggests blood-borne transmission continues to drive Africa’s peculiar HIV epidemics. Unlike epidemics in almost all countries outside Africa, women in Africa are infected more often than men. Outside Africa, HIV is rare except in adults who inject illegal drugs and men who have sex with men; whereas in much of Eastern and Southern Africa, as many as 20%-50% of adults, most with conservative sex lives and often an HIV-negative spouse, can expect to get HIV during their lifetime.

Missing an opportunity to find and fix unsafe health care

In 1988, Russia investigated an unexplained HIV infection in a child with an HIV-negative mother – thereby uncovering and stopping a chain of transmission through unsterile procedures in 13 hospitals that spread HIV from one to 265 children in 15 months. Several years later, tests in four African cities (Kampala, Kigali, Lusaka, and Dar es Salaam) on 5,593 inpatient children and their mothers found 61 children (1.1%) to be HIV-positive with HIV-negative mothers. Instead of initiating investigations, WHO staff blithely and incredibly concluded “the risk of…patient-to-patient transmission of HIV among children in health care settings is low” (p. 85, 1992-1993 Progress Report, Global Programme on AIDS).

The health aid community has spent billions on HIV prevention messages for Africans focusing almost exclusively on sexual risks. Such messages, with their roots in European and American racial prejudices, smear all Africans – including millions of HIV-positive married women with HIV-negative husbands – with suspicions of uncontrolled sexual behavior.

Although the health aid community has done its best to ignore HIV from unsafe health care in Africa, the US Congress has not only been aware of the problem, but has also made available billions of dollars to fix it. In 2003, the US Congress pressed USAID and CDC to spend $300 million allocated for HIV prevention to improve injection safety and blood safety, primarily in Africa. In 2008, when Congress approved $48 billion for HIV aid, primarily for Africa (see: http://www.pepfar.gov/documents/organization/108294.pdf), it asked the President to develop a 5-year strategy, including (page 8): “(C) promoting universal precautions in formal and informal health care settings; (D) educating the public to recognize and to avoid risks to contract HIV through blood exposures during formal and informal health care and cosmetic services; (E) investigating suspected nosocomial infections to identify and stop further nosocomial transmission…”

At the same time, Congress (page 39) asked the US Global AIDS Coordinator to submit an annual report assessing impact on “capacity to identify, investigate, and stop nosocomial transmission of infectious diseases, including HIV and tuberculosis…” Regrettably, during 2008-13, USAID and CDC spent nothing on outbreak investigations in Africa or to warn the public about blood-borne risks. Instead, USAID and CDC promoted more invasive procedures – male circumcision in unreliably sterile conditions – to reduce HIV infections.

Ebola shines a spot-light to unsafe health care

In 2014, West Africa’s Ebola outbreak exposed unsafe health care systems. Health aid managers were quick to acknowledge that health staff are at risk – this was impossible to deny as more than 100 doctors and nurses died. On the other hand, health aid managers have been silent about patients getting Ebola from unsafe health care.
Health aid managers have for decades been able to get away with a head-in-the-sand response to HIV from unsafe health care. This has been possible because HIV infections from health care are relatively easy to ignore – most victims don’t recognize their infections, which are silent for years. Even when unsafe health care fuels atrocious HIV epidemics, health aid managers have been able to divert attention, adding insult to injury, by blaming infections on victims’ supposed sexual misbehaviors.

With Ebola as with HIV, health aid managers are faced with the choice between warning the public to be wary of skin-piercing health care procedures or staying silent about the risk and thereby allowing preventable infections. With HIV, health aid managers’ have chosen to deny problems, even at the cost of millions of unnecessary infections. With Ebola, however, health aid managers may not have that option. People who see family members, friends, and neighbors get Ebola within days after health care procedures may demand action to find and stop unsafe health care procedures.

If West Africa’s current Ebola outbreak gets people to see and stop reuse of unsterile instruments in health care, the beneficial consequences of the current outbreak – fewer HIV and other blood-borne infections – could far outweigh its current terrible human costs.