Bloodborne HIV: Don't Get Stuck!

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).

A group of researchers in Cameroon have carried out the sort of research work that UNAIDS is loath to do. They investigated levels of unsafe reuse of injecting equipment in hospitals. Generally, such investigation only goes as far as to observe injecting behavior in hospitals and health facilities, where the health workers know they are being observed and can adjust their behavior accordingly.

These researchers looked for misconceptions about injection safety that could lead to unsafe reuse of equipment. They also established whether unsafe reuse was related to shortages of injection equipment. They found that equipment reuse is common, being practiced by 44% of health workers in public hospitals. They also found that there is a shortage of equipment.

It was concluded that injection safety interventions could significantly reduce transmission of HIV, hepatitis B (HBV) and hepatitis C (HCV). In addition to effective interventions, the researchers recommended the use of autodisable syringes, which break after use and so can not be reused.

The mixed messages African people get from UNAIDS have got to stop. If the UN can not guarantee the safety of conditions in African hospitals for their own employees, nor can they guarantee safety for Africans, who have little or no option about which health facilities they can use. UNAIDS also needs to stop claiming that 80, or even 90% of HIV is transmitted through unsafe heterosexual sex in African countries.

An article from Zimbabwe asks ‘Is the [HIV] message clear enough for the youth?’ After all, various HIV campaigns have been going for many years. But many of these campaigns depict HIV positive people, and those at risk of being infected, as immoral and as people who are involved in all sorts of ‘disreputable’ activities.

Then the article introduces ‘Shirley’, who is 18 and thinks she knows everything about HIV. Yet, after donating blood, she was called by the clinic and asked to make an appointment to see the doctor there. She turned out to be HIV positive. She was already sexually active but she generally took precautions, with a couple of exceptions.

It appears from the story  that Shirley is still not aware that she is more likely to have been infected in the blood donation clinic than through having unprotected sex ‘a couple’ of times. But she told her partner the results of her test, who refused to be tested himself, and the relationship has now ended.

Shirley concludes from this that her former boyfriend infected her, even though she doesn’t even know whether he was infected or not. HIV prevalence among teenage males is usually considerably lower than among females, so it is very likely that he is HIV negative and that, even if he is HIV positive, he is still unlikely to have infected her after so few sex acts.

The blood donation clinic in Zimbabwe needs to investigate the possibility that this young woman was infected as a result of donating blood. The VCT clinic she attended, more importantly, needs to ask clients about their non-sexual risks, as well as their sexual risks. Especially when the risk of sexual exposure was so low. And children, in and out of school, need to be informed of the non-sexual risks they face in order to take precautions.

That’s what this site is about, letting people know that HIV transmission is not just about sex, it is also about contaminated blood and other bodily fluids that people can come into contact with when visiting health and cosmetic facilities.

Welcome all!

The purpose of this blog and website is to help people protect themselves from HIV during medical and cosmetic procedures, such as getting an injection, having one’s head shaved, getting a tattoo or pedicure, or going to the dentist. Check through the A-Z of site content to see if you might be taking any risks!

We intend to develop this site with contributions from visitors. We’d like to include posters and other training materials, couselling guides, and whatever else might be useful to help people recognize and avoid HIV from blood contacts.

Substantial updates and improvements will be highlighted in the blog. We will also list pertinent articles that appear mentioning HIV transmission through healthcare and cosmetic procedures.

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