Bloodborne HIV: Don't Get Stuck!

An article about “the role of blood-borne HIV infections from unsanitary healthcare procedures” is a couple of years old now, but it’s so rare to read anything about non-sexually transmitted HIV written by an institution connected with the UN, it’s still worth reading. It could be years before they cover the subject again.

This article responds to research published in the International Journal of STDs and AIDS which shows that risks of hospital acquired HIV infection are very high in many developing countries, particularly those in Africa which have the highest prevalence rates in the world.

The authors of the research try to understand why non-sexual HIV transmission, through unsafe medical procedures, is so understudied. In fact, UNAIDS and other well funded bodies even deny that such risks play a part in serious HIV epidemics, though they have never succeeded in explaining how serious epidemics arise in the first place.

The usual explanation is that individual sexual behavior is responsible for about 80% (or even 90%) of HIV and most of the other 20% is transmitted from by mothers to their children. But no one has ever found people who engage in high enough levels of sexual behavior to explain the 80% figure. And some countries have found that up to 20% of HIV positive infants have HIV negative mothers.

While the well funded HIV institutions either imply or state that infants must have been infected sexually, perhaps by their father or another relative, such levels of sexual assault have never been identified anywhere, nor would very high levels of these kinds of behavior be enough to give rise to HIV prevalence rates found in Swaziland, Botswana, South Africa and other sub-Saharan African countries.

Enough research has been carried out to show that medically acquired HIV transmission certainly occurs, and that it might even occur a lot. And while sexual transmission of HIV is very inefficient, medical transmission is many times more efficient, with some procedures carrying up to 100% probability of transmission, for example, contaminated blood transfusions.

The only thing missing is proper investigation. Those who fund HIV research and carry it out seem unwilling to do research that would either confirm their contention that medical transmission hardly ever occurs, or indicate that HIV prevention efforts need to concentrate a bit less on individual sexual behavior and more on what goes on in hospitals and other health facilities.

The debate goes on. One might expect scientists, or anyone with at least some small acquaintance with scientific research, to give greater credence to those who have carried out and published research. But this doesn’t appear to be the case, not yet anyhow. Those opposed to the view that non-sexual HIV transmission could be more common than currently estimated are also strongly opposed to investigating or researching the issue.

In addition to suggestions that non-sexual transmission is ‘kept off the international agenda’, others have pointed to double standards in research ethics, healthcare safety and scientific studies; evidence showing that hospital acquired HIV transmission is common has been knowingly withheld in African countries, evidence that would be made public in Western countries, even in the countries who have funded the research in question.

An ‘expert’ called Francois Venter took the usual option chosen by defenders of the HIV industry status quo: he branded those who disagreed as conspiracy theorists. Yet he accepted that too little work has been carried out in this area. However, there is no hint of conspiracy in the published work of those who are calling for further investigation. This kind of ad hominem response does nothing to strengthen the case for the HIV industry.

The same expert even claims that unsafe needle practices in health facilities does not explain why relatively wealthy countries like Botswana and South Africa have more severe HIV epidemics than less wealthy countries in Africa. This shows that he really doesn’t understand the claim that is being made. Far more people in high HIV prevalence countries like Botswana and South Africa have access to health facilities, and therefore face more risks than those in countries where the majority of people hardly ever get near a health facility.

The idea that most people in countries like Uganda, Tanzania and Kenya are protected from HIV infection because their health services are so poor is a terrible indictment on the understanding that Venter and his colleagues have of HIV transmission in Africa. But a number of studies have shown that proximity to urban areas, roads and health facilities is associated with higher HIV prevalence. Those in rural areas, away from roads, health facilities and other services, are far less likely to be infected.

Lying about non-sexually transmitted HIV, or keeping people from researching and publishing about it, is not going to protect people who are currently being infected. Nor is it going to reduce the levels of stigma that build up around a disease that is said to be mainly transmitted sexually. UNAIDS and the rest of the industry needs to come clean and do some convincing investigative work.

What chills me most about the UK’s lifting of the ban on gay men donating blood is not the prejudice that lies behind such a ban, though that is shocking enough; it’s the fact that the UK does not appear to have much confidence in its health services. Their ’12 month deferral period’ instead of an outright ban does little to assuage any fear people may have.

If the blood transfusion services are not able to screen blood that may be contaminated with HIV and other blood-borne viruses, why just ban gay men from donating blood? What about people who face other sexual risks? And what about people who face non-sexual risks, for example, those who receive health care or cosmetic services that may not be 100% safe?

Another question that this issue raises is about how well the blood transfusion service can assess risk if they will not allow a donor to donate blood even if they are practicing safe sex. Are these health professionals telling us that safe sex is not really safe, or that it’s not safe enough? Or are they just telling us that they can’t really guarantee the safety of the blood? Are the donors even safe?

I raise these questions because there is always lot of dithering about blood-borne risks for HIV transmission, especially relative to sexual risks. During the Football World Cup in South Africa last year, the media drooled over estimations of how many sex workers would be operating in the various cities where matches were being played, how many customers they would have and various other salacious irrelevance.

But nothing was mentioned about the risks people could face if they went to a dental clinic, a hospital, a tattoo parlor or even a hairdressing salon. Half a million people descended on a few South African cities, the country with the highest number of HIV positive people in the world, and no mention was made of the most serious HIV risks that exist.

Of course, many people from Western countries travelling to African countries get advice from guide books, embassies, travel shops and travel agencies. But these don’t usually extend to cosmetic services. Should the UK also ban blood donations from foreigners, travellers, migrant workers and others suspected of falling into one of these groups? Or perhaps they would settle for a 12 month deferral period for them, too?

One commentator points out that HIV is not purely transmitted by men having sex with men. This is true, a small percentage of people infected in the UK are not gay and/or not male. And a large percentage are infected through intravenous drug use. But more importantly, HIV is not purely transmitted through sex; it is not just a sexually transmitted disease.

HIV risk is not confined to sexual risk. And while health and cosmetic services in Western countries are far less likely to use contaminated instruments now, compared to in the 1980s, the very fact that people still see HIV as an STD is worrying. It means that they will not recognize serious risks when faced with them, nor will they know how to avoid them.

Health providers have a duty to inform people fully about sexual and non-sexual risks and how to avoid them. A selective ban, partial or otherwise, on those felt to be ‘most at risk’ represents a failure to give people comprehensive advice about all types of risk and leads to a piecemeal and, as it happens, stigmatizing health policy.

A recent UN report about hazardous medical waste, such as glass, blades, needles and the like, much of it contaminated with blood and other bodily fluids, highlights a serious risk that people in African countries face.

The UN report concentrates on the problems of how to dispose of this kind of waste safely and even mentions the fact that some rich countries find it more convenient to dump their waste in developing countries, where regulations may be less well enforced, if there are regulations.

The possibility of those exposed to the waste suffering needlestick injuries and the effects of low levels of radiation should not be ignored, either by the countries where the waste is being dumped or by the countries doing the dumping. Illegal shipping and dumping of waste and its subsequent inappropriate storage and disposal should not be tolerated; and it is unacceptable to pass the blame to those in poor countries who profit from these practices.

The World Health Organization is quoted as saying “millions of cases of hepatitis and tens of thousands of HIV infections could be prevented each year if syringe needles were disposed of safely instead of getting reused without sterilization”. Medical waste can be rendered safe before being shipped to countries where the recipients may not know the dangers and are unlikely to handle it appropriately.

But the article highlights another problem that people in African countries will notice: medical waste generated here is not always disposed of safely, either. While taking a walk through many hospitals and other health facilities, you may notice the odd syringe, needle, scalpel blade or other instrument on the grass, in hedges or in dumped piles. Most health facilities simply don’t have the capacity to dispose of waste safely, as a look at Service Provision Assessment Reports for various African countries will show.

Members of the public, as well as health personnel, are at risk from medical waste disposed of unsafely. Both adults and children run the risk of contracting bacterial infections, hepatitis, even HIV. The risks may seem small, but the number of times that people come into contact with contaminated waste could be very large, which translates into a far greater danger.

Not all contaminated waste comes from health facilities, either. Many people use syringes, blades and other items in their own homes. Many unregistered vendors selling pharmaceutical products give injections. Cosmetic facilities, such as salons and even roadside manicurists and pedicurists can also have contaminated waste that they need to dispose of.

The number of people who come into contact with potentially hazardous waste could be very high indeed.

Did contaminated blood transfusions make a significant contribution to the HIV pandemic? In wealthy countries, the answer is clearly ‘yes’, blood transfusions and use of blood products was already very common when HIV was identified. Until the role of these procedures in HIV transmission was recognized, many people were infected with HIV nosocomially.

But could blood transfusions have made such a contribution to the most serious HIV epidemics in the world? Often, it is said or suggested that transfusions were not common enough in developing countries, particularly the African countries that have experienced the worst HIV epidemics. But an article published by William H. Schneider and Ernest Drucker five years ago shows that this view is mistaken.

The authors estimate that “approximately 20 million transfusions [were] done in sub-Saharan Africa during the 1980s” and that “30 to 40 million transfusions occurred in sub-Saharan Africa in the period 1950–1990.” If HIV began to spread in the 1960s in the virus’s country (or countries) of origin and had already reached several other countries by the 1970s, there would be ample opportunity for HIV to spread widely in health facilities and via health services.

Interestingly, blood transfusions started in what is now the Democratic Republic of Congo. The highest levels of genetic diversity in HIV are found in DRC, suggesting that the virus has been there for longest and probably originated there. The authors also find that blood transfusions were probably far more common among urban populations. HIV is still far more common among urban populations and is only slowly moving to more isolated areas.

Once HIV became endemic in many African countries, it would have been a short step to relatively high levels of sexual transmission. But the history of blood transfusions in African countries, along with histories of medicine in general, mass vaccination campaigns, large scale targeting of specific populations, such as miners, sex workers and truckers, and various other phenomena, show that massive HIV epidemics have never been primarily related to sexual behavior, and this is probably still the case.

Whatever the relative contributions of sexual and non-sexual behavior, Schneider and Drucker’s paper make it clear that we don’t need to posit ridiculous levels of sexual behavior to explain very high rates of transmission among Africans in high prevalence countries. People need to be aware of the non-sexual risks, not just the sexual risks.

Blood donors and recipients of blood transfusions, and recipients of all types of skin piercing medical procedures, need to be aware of the risks and of how to avoid them. The same applies to risks that people may face in cosmetic facilities, such as salons, tattoo parlors and the like.

[For more about racism in global HIV policy, see the HIV in Kenya blog.]

Kenya’s 2010 Service Provision Assessment Survey shows that the majority of hospitals and health facilities in the country don’t have all of the items and services they need to prevent hospital acquired infections. That’s all infections, not just HIV. And that’s everyday items, such as clean running water, soap, surgical gloves and the like.

So it’s not surprising that when there is a disaster, such as the fire at Sachangwan, Rift Valley province, a few years ago, the majority of people who are admitted to hospital subsequently die.

The fire in the Sinai slum a few days ago involves similar numbers as the one in Sachangwan and the Kenyatta National Hospital has run out of “clinical material like bandages” and are appealing for donations.

While UNAIDS documents about HIV transmission never fail to use terms like ‘universal precautions’ to prevent patients being infected with blood borne diseases such as HIV and hepatitis through contaminated blood, during such emergencies, and there are many, it is not possible to screen out blood from people who are in the ‘window period’, during which they may test negative although they are positive.

In fact, both the blood donor and the recipient can face risks when adequate procedures are not followed. Many donors have been infected in the past, probably after equipment was reused without sterilization. And WHO have reported that only 12% of donated blood is properly tested.

UNAIDS may wish to claim that donors and patients face no risks but they don’t even believe that themselves. So it’s worth checking up on the precautions you can take using POST (Patient Observed Sterile Treatment).

Here’s another article about HIV contaminated blood supplies, this time in the Philippines. The article doesn’t say if donors in the country are paid for their blood. Payment can give rise to people more likely to be infected, such as intravenous drug users, coming forward to give blood, sometimes frequently. But there is a shortage of blood at the moment because of a high and rising number of dengue cases. The number of contaminated units has doubled in the last three years. HIV rates have also recently increased by 63%.

It isn’t only receiving blood that can carry a risk of HIV infection, though the probability of transmission through contaminated blood from a transfusion is very high. Those donating can also be infected and this phenomenon is said to have contributed over 10% to China’s current prevalence. Infection occurred after plasma was removed from blood and the remaining fluid was injected back into donors. Infected donors can then return and their donated blood and blood products will infect recipients.

In Las Vegas, unsafe injection practices at an endoscopy clinic were discovered to have transmitted hepatitis C to at least eight patients. A study concluded that patients were ‘most likely’ infected by the reuse of single use anesthetic vials. 50,000 people were notified in the following public health inquiry. The authors of the study noted difficulties in detecting and investigating such outbreaks.

We don’t hear about such incidents in African countries. Is that because they don’t occur, because no one is looking for them or because they remain unreported when discovered? Investigations are possible, though UNAIDS seem to be completely opposed to them. But it’s not as if African health services are in any way unlikely to experience such incidents, quite the contrary.

Given estimated transmission rates of one in 500 from women to men and one in 1000 from men to women, the chances of an individual transmitting HIV several times are very small, credulous claims to the contrary in the mainstream media notwithstanding.

But when a health facility outbreak occurs, numerous infections can result in quick succession. Infections can even spread to several health facilities and further transmissions can continue for lengthy periods within those facilities.

At least 23 children in a hospital in Gujurat have been infected after receiving contaminated blood transfusions. The blood is said to have come from the hospital blood bank, so there may be others infected, as yet undiscovered.

The children infected attend the hospital regularly as they need frequent medical treatment. But anyone attending the hospital needing blood or blood products could be infected, if the infections came through the blood bank.

Could such transmissions occur in African countries? Well, the answer given by UNAIDS is ‘no’. Or at least, they claim such transmissions rarely occur and would only account for about 1% of all HIV transmissions (see Kenya’s Modes of Transmission Survey, for example). But this claim, repeated throughout the HIV industry literature, has always looked like wishful thinking.

What’s to stop such transmissions from occuring? All countries writing HIV/AIDS strategies mention ‘universal precautions’ to prevent HIV transmission through contaminated blood and possibly other types of health care infection. But using the term ‘universal precautions’ does not mean those precautions have any reality outside of the endless supply of HIV/AIDS strategy documents one can find.

According to Service Provision Assessments, on the other hand (see the latest report from Tanzania, for example), which look at health facility conditions and preparedness regarding infection control, most health facilities are lacking many of the most basic capacities. Other documentation tells a similar story.

The fact that one rarely reads about health facility outbreaks of HIV in African countries maybe be because health facilities have, somewhat miraculously, managed to avoid them. Or it may be because many people in some of the worst affected countries do not have access to health facilities, thereby protecting them from such infections.

Whatever the reason or reasons, the issue of hospital acquired infections, especially infections with HIV, hepatitis and other serious illnesses, is in urgent need of investigation.

The attitude of UNAIDS and friends appears to be that African people can’t be allowed to think health facilities may be dangerous places. But if they are dangerous, we have a duty to inform people and a further duty to improve conditions.

For advice on how to avoid HIV and other infections through blood transfusions, read about the POST strategy (Patient Observed Sterile Treatment) on this site.

It’s a point that is not often acknowledged, and often misunderstood, but HIV does survive ‘outside a human body’ for a long time. Searching the issue online, you may think that HIV ‘dies in seconds’ because that’s what it says on many sites, often sites maintained by those who should know better (or perhaps do know better but haven’t got around to saying so yet?).

The question is, do you want someone else’s blood on instruments that are used to puncture your skin?

There have been a lot of instances of contaminated instruments being used on patients in connection with diabetes, testing, monitoring, injecting, etc. Equipment is misused by staff who have not been properly trained. As a result, thousands have had to be tested for HIV and hepatitis and at least 15 people have been infected in the US alone.

Such incidents are probably underreported and might not even be noticed by those who are misinformed about the risks involved. An incident in Wisconsin is particularly interesting and was reported by whistleblowers, rather than by proper infection control procedures. The healthcare worker involved thought it was OK if she changed the needle on a fingerstick pen, not realizing that “blood can backflow into the pen’s reservoir and contaminate the next person pricked by the pen”.

A similar phenomenon can occur when injections are being administered and some healthcare workers don’t realize that it is not enough just to change the needle, while reusing the syringe.

The HIV industry still denies the possible contribution of healthcare related transmissions of HIV in African countries, without having carried out adequate investigations. But it’s a little comfort to hear a CDC epidemiologist saying: “One of the most common myths is that contamination is limited to the needle. An insulin cartridge is a form of syringe. And a syringe and needle should be seen as a single device. One can contaminate the other.”

Let’s hope that what applies in the US also applies in Africa (hint hint, UNAIDS, WHO and even CDC, who have a massive influence in Africa).