Bloodborne HIV: Don't Get Stuck!

An unexplained HIV infection is evidence that skin-piercing procedures at some hospital or clinic may be infecting patients. How to find and fix the problem? The basics are common sense:

• Ask where people with unexplained HIV infections might have been exposed to contaminated blood.
• Test others who had skin-piercing procedures at suspected facilities.
• Find and fix dangerous procedures.

Communities and governments outside sub-Saharan Africa have investigated unexplained infections. These links take you to pages with information and references for investigations in 20 countries (listed in alphabetical order): Argentina, Australia, Cambodia, China, Colombia, Denmark, Egypt, India, Kazakhstan, Kyrgyzstan, Libya, Mexico, Pakistan, Romania, Russia, Spain, Tajikistan, the United States, Uzbekistan, and Vietnam. 

The 12 largest investigated outbreaks from health care

During  1986-2024, investigations of unexplained HIV infections in 11 countries found 12 large outbreaks with at least 100 HIV infections up to an estimated 100,000 infections from skin-piercing medical procedures (see Table 1; references for these outbreaks are in the links above).

Table 1: Investigated HIV outbreaks from healthcare with >100 infections (listed by year of outbreak)

Country, year investigated	Who was infected	Number of cases
Mexico, from 1986	Blood and plasma sellers	281
Russia, Elista, from 1988	Inpatient children	>260
Romania, from 1989	Children	~10,000
India, Mumbai, from 1989	Blood and plasma sellers	~172
China, from 1994	Blood and plasma sellers	~100,000
Libya, from 1998	Inpatient, outpatient children	>400
Kazakhstan, from 2006	Inpatient children	~150
Kyrgyzstan, from 2007	Inpatient children	~270
Uzbekistan, from 2008	Inpatient children	>140
Cambodia, from 2014	Patients attending a clinic	~292
Kot Imrana, Pakistan, from 2018	Patients attending clinics	~669
Ratodero, Pakistan, from 2019	Children, adults attending clinics	~2,800 children

Investigations work!

No country that has investigated to find an HIV outbreak from healthcare has developed a generalized epidemic. HIV epidemics after investigations have been limited. As of 2023, in 17 of the 20 countries with investigations discussed in this blog, the percentage of adults with HIV ranged from <0.1% to 4% only. In three countries: 0.5% were infected in Cambodia, 0.6% in Columbia, and 0.8% in Russia.

Pakistan is the only one of the 20 countries with recent evidence of large-scale transmission through health care; after investigations beginning in 2018-19 uncovered large bloodborne outbreaks in Kot Imrana and Ratodero, 29 HIV-positive children less than 3 years old reported in Mirpurkhas in 2024 (some mothers were infected; HIV-infected children may have infected their mothers through breastfeeding).

In 19 of 20 countries, epidemics were concentrated in men, reflecting risks among (male-male sex and injection drug use). Cambodia is the exception: as of 2023, UNAIDS estimates just slightly more men than women infected. Cambodia’s 2014-15 investigation alerted people to risks to get HIV in health care, which has no doubt reduced those risks. If health care has gotten safer after 2014-15, this will likely change the sex ratio in coming years as fewer women and men get HIV from health care, while low numbers of men will continue to get HIV from injection drug use and sex between men.

Table 2: What happened after investigations discovered HIV from medical procedures?

Country	How many infections from medical procedures discovered in the biggest investigated outbreak?	% of adults HIV-positive in 2023
Argentina	4 (discovered 1992)	0.4%
Australia	33 and 20 (discovered 1990 and 1993)	<0.1%
Cambodia	~240 (discovered 2014)	0.5%
China	estimated 100,000 (discovered 1994)	<0.1%
Columbia	~12 (discovered 1993)	0.6%
Denmark	1 (discovered 1993)	<0.1%
Egypt	82 and 39 (discovered 1990 and 1993)	,<0.1%
India	~172 (discovered 1989); others later	0.2%
Kazakhstan	118 (discovered 2006)	0.3%
Kyrgyzstan	~270 (discovered 2007)	0.3%
Libya	>400 (discovered 1998)	0.1%
Mexico	281 (discovered 1986)	0.4%
Pakistan	>2,000 and ~669 (discovered 2019 and 2018)	0.2%
Romania	~10,000 (discovered 1989)	0.2%
Russia	>260 (discovered 1988)	0.8%
Spain	10 (discovered 1988)	0.2%
Tajikistan	>50 (reported 2006-2014)	0.2%
Uzbekistan	147 (discovered 2008)	0.2%
Vietnam	~40 (discovered 2018)	0.3%
United States	5 (discovered circa 1990)	0.4%

Sources: Percentages of adults aged 15-49 years HIV-positive are from UNAIDS (HIV estimates with uncertainty bounds 1990-2023. The estimate for China is from Zhang et al, Curr HIV/AISA Rep 2020; 17: 151-160. The estimate for Russia is from Ogarkova et al, Viruses 2023; 15: 2156 (figure 3.1 reports just under 0.6% prevalence among all ages in 2022; I adjust that up to 0.8%, considering circa 20% of the population is <15 years old).