Bloodborne HIV: Don't Get Stuck!

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Kazakhstan: cases and investigations

In May 2006, doctors in the Shymkent Region in southern Kazakhstan discovered a child with an unexplained HIV infection. Responding to unexpected infections, “…Kazakhstan’s Health Protection Ministry sent a commission to Shymkent to look into how the children got HIV. On July 14, the Health Protection Ministry released a statement that 14 children, not just the two, were infected with HIV.” In mid-September 2006, investigators reported 54 infections.[2]

In November 2006, investigators reported sequencing of HIV from a number of children showed closely linked infections. Likely one child got HIV through a blood transfusion after which doctors and nurses passed HIV child-to-child through unsterile practices.[3]

In June 2007, Kazakh authorities reported the outbreak investigation had tested more than 10,000 children, finding 118 infected from unsafe health care. Mothers of 14 of the children were also HIV-positive; these mothers were likely infected by their children through breastfeeding.[4]

Numbers of children found with HIV from the outbreak continued to rise. In early October 2007, the South Kazakhstan Regional Health Department reported the ongoing investigation had so far identified 133 children infected through health care.[5] Months later, in January 2008, the Kazakh AIDS Center reported 143 children infected in the outbreak. According to a 2012 report, “roughly 150 children [were] caught up in one of… Kazakhstan’s largest public health scandals.”[6]  The government brought criminal trials against some of the health care workers. The judge presiding over at least on of the trials noted “The rules of the sterilization of medical equipment were blatantly violated in the central district hospital…”[7]

Another study of the outbreak reported (p 79 in this link): “[A]dministration of IV [intravenous] fluids and SVC [sub-venous catheters] were associated with infection among children, possibly because of unsafe practices.” As a part of the study, researchers looked at hospital procedures: “In hospitals, unsafe techniques for administration of IV medications and the use of reusable equipment for catheterization were observed.”[8]


1. RadioFreeEurope. Kazakhstan: 14 children infected with HIV in hospitals. 21 July 2006. Available at: (accessed 12 October 2018).

2. RadioFreeEurope. Kazakhstan: HIV scandal sparks search for those responsible. 17 September 2006. Available at: (accessed 12 October 2018).

3. Trend News Agency. South Kazakhstani children got HIV from a single source CDC. 21 November 2006. Available at: (accessed 12 October 2018).

4. RadioFreeEurope. Kazakh health workers jailed over HIV-infected children. 27 June 2007. Available at: (accessed 12 October 2018).

5. RadioFreeEurope. More HIV-infected children found in South Kazakhstan. 7 October 2007. Available at: (accessed 12 October 2018).

6. Lillis J. Kazakhstan: Shymkent’s HIV scandal, six years later. Eurasianet [internat]. Available at: (accessed 8 November 2020).

7. Kaiser Health News. Health workers sentenced to prison for criminal negligence in Kazakhstan after HIV outbreak among women, children. 2 January 2008. Available at: (accessed 12 October 2018).

8. Sailybayeva JG, Kaspirova A, uatbayeva A, et al. Human immunodeficiency virus (HIV) outbreak investigation among hospitalized children — Shymkent City, Southern Kazakhstan Region. June-November 2006. p 79 in: CDC. 57th annual EIS conference, 22-24 April 2009. Available at: (accessed 12 October 2018).

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