Bloodborne HIV: Don't Get Stuck!

Estimated risk to transmit HIV

If the previous patient was HIV-positive and the provider reuses the needle and syringe, or even just the syringe, with no effort to clean, your chance to get HIV from a shallow injection (intramuscular or sub-cutaneous) may be estimated at 0.5%-3%. For an deeper injection (intravenous, or into a vein), the risk may be estimated at 3%-10%. Your risk may be much less if the syringe or needle are wiped or rinsed after use. Your risk may be greater if what is injected comes from a multi-dose vial.

POST can protect, but it’s not always doable…

The POST idea promoted on this web-site grew out of recommendations from the Safe Injection Global Network (SIGN). After a 1999 paper in the Bulletin of the World Health Organization estimated as many as 100,000 HIV infections per year in Africa from unsafe injections, the WHO with support from the US CDC and others established SIGN. SIGN recommended shifting injections from reusable glass syringes to single-use plastic syringes along with messages to the public to generate patient demand for single-use syringes. Using the POST idea to assess injection safety, national surveys in Africa and asked people (quote from page 481): “The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?”

However, there were and are slips between cup and lip. If providers follow CDC and WHO directions for how to give safe injections, it is difficult if not impossible for patients to see syringes and needles taken from sealed plastic packages in front of patients and that what is injected has been managed so it cannot have been contaminated. CDC recommends: “Prepare vaccines in a clean, designated medication area away from where the patient is being vaccinated…” . Also: “If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated clean medication preparation area (e.g., nurses station), away from immediate patient treatment areas.” WHO recommends: “Injections should be prepared in a designated clean area where contamination by blood and body fluids is unlikely.” 

In other words, SIGN’s recommendation to show patients that syringes and needles come from sealed bags is no longer the gold standard for safe injections. And SIGN never proposed any way for patients to see that what is injected has not been contaminated, ie, is from a single-dose or multi-dose vial opened in front of the patient. A workable POST strategy for injections would ask providers to give injections with pre-filled syringes taken from packages in front of patients. But that’s not yet on the agenda…

POST for injections
1. Avoid skin-piercing procedures	When your doctor prescribes an injection, ask if you can get along without any medicine, or if an oral alternative is available. Many conditions, such as colds, flu, dry cough, and diarrhoea are often better treated without injected medicines. The following drugs and other substances can be taken orally, and should be injected only in rare situations (especially if someone is unconscious, or vomits so much that oral medication will not stay down): vitamins glucose paracetamol and other drugs to reduce temperature most pain-killers treatments to stop diarrhea or vomiting medicines to treat asthma antibiotics (with a few exceptions, such as penicillin) Most sexually transmitted disease (STD) can be treated with oral drugs. The most common exception is syphilis, which is often treated with injected penicillin. One injection of long-acting penicillin is safer than 7-10 daily injections of short-acting penicillin. (Old syphilis infections may require repeated injections of long-acting penicillin.)
2. Use new disposable instruments	If your provider agrees: Ask him or her to take a new disposable syringe and needle from a sealed package OR if you can buy and bring a new syringe and needle in a sealed package. If your provider agrees: Ask him or her to take medication to inject from a single-dose vial (a small bottle with medicine for one injection only) or multi-dose vial (in many countries, vaccines are available only in multi-dose vials). In many countries you can buy and bring most medications except vaccines. Many providers stock only multi-dose vials (with medicine for many injections). You can ask your provider to write a prescription for a single-dose vial, which you can buy at a pharmacy. If no single-dose vial is available, ask your provider to take medicine from a new multi-dose vial opened in front of you. This is especially important for local anaesthetics. (Exception: If your provider uses a new syringe and needle every time he or she takes medicine from a multi-dose vial, there is no chance for blood or HIV to get into the vial. Can you be sure?)(c) Another option is to take injections from pre-filled disposable syringes– which are disposable syringes combined with single-dose vials, or single dose cartidges. Single dose cartidge NOT YET AVAILABLE: To make POST work for injections, what is injected should be available in prefilled single-use syringes, which can be taken from packages in front of patients. In the future, several options might be small plastic bulbs with medicines connected to small needles (uniject or apiject syringes) or pre-filled conventional syringes.
3. You sterilize the instruments	It’s safer not to do this. If you keep reused syringes and needles at home, even if you boil them after use, it’s easy for them to pick up germs from hands, cloth, and air.
4. Ask providers how they sterilize instruments	Your provider will have to use special reusable syringes and needles in some situations, such as to inject rabies vaccine. These are situations where you can talk with your provider, but in the end you have to trust them.

Assessing SIGN’s impact after 25 years

SIGN won a lot of battles: Combining information from more than 20 surveys across Africa during 2011-15, 96.7% of those who reported a recent medical injection said the syringe and needle came from a newly opened package. No doubt a lot has changed. No doubt shifting to plastic syringes has curtailed reuse of contaminated syringes. But how much has changed? The very high percentages of patients who said they saw providers taking syringes and needles from sealed packages seeming conflicts with recommendations for how to give safe injections. 

SIGN has not won the war: Unexplained infections have continued on a large scale in sub-Saharan Africa. If the war is to stop transmission through medical procedures, the war is not won; not by a long shot. SIGN started off on the wrong foot — proposing a cure (shifting from reusable to single-use syringes) without a diagnosis. A diagnosis, both then and now, requires outbreak investigations to trace unexplained infections to their source. Maybe injections are involved at times; if so, what are the specific errors that allowed blood transfer? How much comes from other medical procedures or cosmetic procedures. The war is not won. To do so, communities and governments must identify specific targets, specific errors to fix.

Evidence that medical injections infected people with HIV

One of the best ways to estimate risks to get HIV from injections is to follow people who are HIV-negative, testing them periodically and asking everyone about risks between tests. Information on new HIV infections in adults with or without injections between tests is available from 10 such studies in Africa during 1984-2008. Taking all studies together, 12 of 13 results show that men and/or women who reported injections were more likely, often many times more likely, to show up with a new HIV infection compared to those who reported no injections (see the column on the right in the Table, below).

*These statistics are odds ratios from case-control studies. ^This result is based on reported hormone injections for birth control.

Additional information on injections

Reused syringes are dangerous, even with new needles: When someone receives an injection, some of their blood can get into the needle and syringe through back pressure from their muscle and through suction when the needle is withdrawn from their flesh at the end of an injection.

Disposable syringe and needle

If a provider then changes the needle to reuse the syringe with a new needle, blood in the old needle can get to the tip of the syringe through suction when the needle is removed from the nozzle of the syringe. There is good evidence for this: In an experiment more than 50 years ago, researchers filled syringes with sterile solution, injected some of the solution into mice with a deadly infection, changed the needles, and then with the same syringes injected the remaining fluid into healthy mice. Within two days, infections from these injections killed more than 70% of the formerly healthy mice.[iv]

Glass syringe and needle

Many providers do not know this is dangerous. For example, 91% of health care staff in Ethiopia[v] in 2003-04 thought an injection was safe if the provider changed the needle but reused the syringe. A study of immunization injections in Swaziland in 1997 found that health staff in 8 of 26 clinics changed needles while reusing syringes.[vi] In 1987 WHO warned, “A dangerous practice has slipped into common use…: changing needles but using the same syringe for several consecutive injections.”[vii]

Multi-dose vials: Most injected vaccines and drugs come from multi-dose vials (small bottles that contain doses for many injections). Medicines in multi-dose vials may be contaminated with HIV or other pathogens. This can happen if a provider reuses a syringe – even with a new needle – to withdraw medicine from a vial. If HIV gets into the vial, it could survive for weeks, waiting to get into other patients. Multi-dose vials of local anaesthetic are especially dangerous. After an initial injection of local anaesthetic, some patients continue to feel pain. In such cases, providers might re-use the same syringe to withdraw another dose of anaesthetic for a second injection; this could contaminate the vial.

Multi-dose vial

Multi-dose vials have spread hepatitis B and C viruses in the US. In Australia, a multi-dose vial of local anaesthetic is suspected to have passed HIV from one HIV-positive patient to four others visiting a doctor’s clinic in one day.[xi]

Depending on the drug and vaccine, you can often but not always find single-dose vials available in your country. But for some medicines or vaccines, it may be difficult or impossible for you to avoid multi-dose vials.

Some injection providers routinely leave a needle embedded in the cap of a multi-dose vial. This is an added risk, because the needle provides a pathway for pathogens from the air or from hands or anything else that touches the needle to get into the vial.

Some medicines come in dried or concentrated form, and must be mixed with distilled water before injecting. The distilled water usually comes from a large bottle used to mix other medicines. Think of this large bottle as a multi-dose vial that can be contaminated; you can ask the provider to take saline water from a small or new bottle.

Are untrained providers a risk? Many people give injections – not only doctors and nurses, but also pharmacists, traditional healers, family, and friends. No general statements can be made about who gives safe injections. If a trained provider respects your requests, uses a new syringe and needle, and takes medicine from a single-dose vial, you are probably safer with the trained provider. But if the trained provider will not do so, you may be safer with an untrained provider who will listen to you.

Long-standing syringe and/or needle reuse in Africa: Reuse of syringes and/or needles has been a long-standing problem, going back to colonial times. During 1995-98, WHO surveyed injection practices in 13 African countries. A summary of findings from these surveys concluded that “the study countries have not made any progress with regard to safety over the last 10 years.” [viii] In 1999 WHO estimated that 50% of injections in Africa reused syringes and/or needles without sterilization.[ix] Despite improvements over the last 10-15 years, unsafe injections remain all too common. In 2002, WHO estimated that 17-19 percent of injections in Africa reused syringes and/or needles without sterilization.[x] In 1999, WHO established a Steering Committee on Immunization Safety. The Committee’s first report recognized that “up to one-third of immunization injections are not carried out in a way that guarantees sterility.”[xii] 

References