Bloodborne HIV: Don't Get Stuck!

A Tanzanian organization called Sikika (meaning noticeable or audible) has surveyed 30 health facilities and 71 districts (just over half of all districts) to assess the availability of medicines and medical supplies, concentrating on absorbant gauze, but also looking at supplies of surgical gloves, syringes, ALU (Artemether/Lumefantrine, for treating malaria), quinine injections and amoxicillin. The findings are very disturbing. Up to 50% or more of the facilities lacked supplies of at least one of the surveyed items. Up to 50% or more had no gauze, 40% had less than they needed and only 8% had sufficient supplies. Shortages could last for up to six months.

This can be compared to the work that Marc Koska did to demonstrate to health officials in Tanzania that there was a need to look at the role of injecting equipment reuse in transmitting HIV and other blood borne viruses, reviewed yesterday. These shortages are extremely unlikely to be confined to the five surveyed items, either. Representatives of the Ministry of Health and Social Welfare and of the Medical Stores Department did not respond to the survey.

The researchers do not appear to have asked what health professionals do when they have run out of such supplies. Do they treat fewer people, do they reuse supplies, with or without an attempt to sterilize them? Myself and a colleague have asked people working in healthcare that question; they appeared to think it obvious that they would reuse supplies. The report lists various contingency measures, such as borrowing from neighbouring hospitals, asking patients to supply, sending patients to other facilities, etc. But if most hospitals don’t have enough supplies these measures must be limited in effect. Some cancelled elective surgeries and others suggested that the numbers of cross infections and complications would increase as a result of shortages.

The study aimed to survey the extent of the problem, find out what was being done about it and how patients were affected by it. They also interviewed health officials from Uganda and Kenya to compare the three countries. Some of the shortages were due to lack of funds available to individual facilities. Orders were placed for lower levels of supplies than required and surgery had to be cancelled for all but emergency cases. But the entire procurement and distribution process was found to be in urgent need of revision.

The study also highlights a massive shortage of public pharmacies, even in areas which are not particularly isolated, such as Dodoma, the administrative capital of Tanania. There are only about 700 trained pharmacists in the whole country, which has a population of over 40 million, and pharmacies are concentrated in cities and big towns. Over 75% of tanzanians live in rural areas. Medicines and medical supplies are all procured through the Medical Stores Department, a centralized agency, and they are currently reforming their delivery system.

Shortages of supplies other than gauze were less severe, with shortages of syringes being least severe. But there were still 6% of facilities at district level and another 10% of facilities interviewed that had no supplies. 50% of facilities were short of syringes. The figures for lacking surgical gloves were 28% and 17%, respectively, with 58% suffering from shortages.

Conflicting information was received from Kenya and none at all from Uganda. Kenya did experience shortages of gauze, said to be due to a global shortage of cotton. Africa, including East Africa, produces a lot of cotton. But that is unlikely to have much impact on medical supplies that mainly come from large pharmaceutical multinationals, rather than from non-Western manufacturers.

I can certainly see why UNAIDS would recommend to its employees that they avoid health facilities that are not approved by the UN when working in African countries. But I don’t understand why UNAIDS don’t think that Africans themselves are in any danger. Are Africans not entitled to the same warnings about unsafe healthcare as UN employees?

Marc Koska’s SafePoint Trust got some well deserved coverage in the English Guardian last Friday. Having spent years researching and building up the skills necessary, he developed a syringe that cannot be reused. Despite UNAIDS’ and WHO’s constant denials, reuse of injecting equipment is very common in poor countries, where there is a high prevalence of blood borne viruses such as HIV, hepatitis and many bacterial infections. Such reuse is also extremely dangerous; in the case of HIV, risk of infection from reused injecting equipment is many times higher than unprotected heterosexual sex.

Exclusive use of this technology for preventive and curative injections will be pioneered in Tanzania. Koska used some secret filming of injecting equipment reuse to persuade the Minister of Health and Social Welfare of the need for such a change in injecting practices. She was convinced. The WHO does, to a limited extent, accept that there is a problem. They say 1.3 million people die from injecting equipment reuse every year. They just don’t bother making it clear to people in high HIV prevalence countries how common these practices are, or how people can avoid being infected.

SafePoint also adds some of the estimated figures for people infected with serious and life-threatening diseases from syringe reuse: an estimated 7 billion of the 17 billion injections administered every year are unsafe; 21 million transmissions of hepatitis B and 2 million of hepatitis C; 20 million medical injections in Africa alone contaminated with HIV; more than half of HIV positive transmissions in children in Europe were a result of contaminated equipment reuse in Romania, alone.

Asking people here in East Africa who work in healthcare about injecting equipment reuse, including those specializing in HIV, generally elicits denial, even hostility. Many people are vaguely aware that HIV can be transmitted through non-sexual routes; they just happen to swallow the HIV industry’s reassurances that almost all transmission is through heterosexual sex. Because they don’t see non-sexual routes as a threat to their health or the health of their families, they pay little or no attention to avoiding the risk.

Koska tries to hammer the point home by citing figures for the difference between the number of injections administered and the number of syringes imported. He finds that “Tanzania has 45 million people and they are importing 40m syringes. With an average of five injections each a year, they need 220m”. As he reminds us, immunization only accounts for about 10% of injections, the other 90% being accounted for by treatment.

Self-destruct or ‘autodisable’ syringes, such as the ones Koska’s company manufactures, are as cheap to produce  as non-autodisable syringes. However, it is slow to change practices where commercial interests are involved. Given UNAIDS’ and WHO’s lack of interest in non-sexual transmission of HIV and other diseases, indeed, their active opposition to warning Africans against such threats, it is not surprising that manufacturers of these unsafe syringes see no reason to make changes.

Let’s hope Koska’s SafePoint Trust program in Tanzania reveals something of the true extent of the problem so that other medium and high HIV prevalence countries can follow suit so that infection rates can be cut, perhaps substantially.

[Watch the five minute video about Koska’s SafePoint campaign and the undercover filming of contaminated syringe being used on a HIV positive man and reused on an infant.]

The Citizen has an article about Tanzanians being reluctant to donate blood in the Mbeya region, in the South of the country. The article suggests that there is a lack of awareness about the safe blood program that gives rise to this reluctance.  Apparently, some people fear that donating blood will do them some harm.

While people needn’t worry about donating blood making them sick or weak, they might have reason to worry about the safety of the blood transfusion services. There may also be legitimate worries about receiving a transfusion in places where infection control procedures are poor, such as Tanzania. Mbeya is also one of the high HIV prevalence regions, with rates far higher than average.

Shortages of donated blood can lead to avoidable deaths. But it would be wrong to insist that everything is perfectly safe for donors and those receiving transfusions when this may not be the case. Perhaps the World Health Organization, in its great wisdom, will investigate the safety of blood transfusion and other services that may risk transmitting HIV, hepatitis and other blood borne diseases. Otherwise their assurances are useless.

A Tanzanian researcher, Dominic Mosha, carried out a study into the safety of pediatric blood transfusions in two hospitals in the North of Tanzania. He found that only 10% of the blood transfused came from the blood bank. The other 90% came directly from donors, often family members. The blood from direct donors was screened for HIV and syphilis, but it was not screened for hepatitis B and C.

Instead of calling for more people to donate and letting them think they are perfectly safe in doing so, it would be far better to accept that there are some problems and to work with the relevant authorities to resolve these. But lying about the risks when they have not been properly investigated is not going to increase confidence in blood transfusion services or health services in general.

The San Francisco Chronicle has an article about glucose meters for diabetics being reused without cleaning. People with diabetes have been found to face double the risk of being infected with hepatitis B compared to those without diabetes. The Centers for Disease Control recommend vaccinations against hepatitis B and other measures to reduce likelihood of transmission.

Dr Joseph Sonnabend sent me the article, pointing out that this is the situation in industrialized countries, where health services are in far better condition than in developing countries, where rates of hepatitis B and other blood borne viruses can be very high. In such scenarios, it would probably be advisable to test for hepatitis C and HIV also.

Dr Sonnabend points out that diabetes is a complication of some commonly used HIV drugs. But it is also very common in countries where poor diet and other factors lead to high disease burdens. Many people in developing countries who develop diabetes are unlikely to be tested until the condition has reached a critical stage and they are also less likely to receive treatment, because of cost, lack of access to health facilities or a combination of problems.

Apparently outbreaks of hepatitis B have been common among diabetics for many years. Therefore, those in developing countries who do have access to health facilities may face far higher risks from hepatitis B, C, HIV and perhaps other blood borne diseases. It just seems unlikely that infection control procedures in these countries will pick up the thread and deal with it adequately.

UNAIDS and other institutions seem keen to deny the possibility of reuse of contaminated skin piercing instruments in health facilities giving rise to infection with HIV or other diseases. But the only reason people in high HIV prevalence countries are unlikely to face such risks seems to be that many of them are unlikely to be able to afford treatment.

A recent study indicates that use of injectable hormonal contraceptives, such as Depo Provera, may double transmission of HIV from HIV positive men to women receiving the injections and also from HIV positive women receiving the injections to HIV negative men with whom they have unprotected sex.

A family planning expert in Rwanda, Dr Thomas Nsengiyumva, finds the study to be misleading. He points out that one sexual partner must be HIV positive for this doubling of risk to occur, and they can reduce the risk considerably by using condoms.

This is true; no sexual contact between HIV negative couples gives rise to HIV transmission; and using condoms consistently and properly always reduces the risk of pregnancy and sexual transmission of HIV and other sexually transmitted infections.

Pathfinder International, who receive large amounts of funding (annual budget of over 100 million dollars) to promote family planning and reproductive health information and training in developing countries have also expressed their scepticism about the study. I agree with them that “premature speculation” can be dangerous. But this speculation doesn’t come from nowhere: it comes from the uncertainty that the HIV industry has created by not giving clear or convincing advice to users of the injectable drug.

If Pathfinder are really concerned about mother to child transmission of HIV, as they claim to be, there are far better ways of addressing that than by simply doling out various family planning commodities.

The HIV status of one or both partners in a relationship may not be known, or it may change without one or either partners being aware. So, in partnerships where one partner is known or suspected to be infected with HIV, or who may become infected, would it not be better for the female partner using injectable hormonal contraceptives to give up doing so and to rely on condoms, or some other method or combination of methods?

Findings about hormonal contraceptive drugs going back many years, decades even, show that they are questionable, that they have other risks besides HIV transmission. The most recent findings seem more like another nail in the coffin for such methods, at least until their safety has been assured. Injectable Depo Provera and similar drugs have not been shown to be safe.

Would people in Western countries accept the ‘reassurances’ of WHO that women should continue using Depo Provera until they have had time to discuss the issues? I think the advice to people would be immediate, however lengthy the discussions need to be. But, as it happens, most people in Western countries don’t use injectable hormonal contraceptives, unless they are poor or of African descent, or both, as is often the case.

The ‘dilemma’ seems to be: stop using the drug and risk unplanned pregnancy OR continue using the drug and risk unplanned pregnancy AND HIV transmission? Condoms and other methods are available, effective and cheap and can be used on their own or in combination, with reference to the specific needs of each user. Is that really such a dilemma?

The HIV industry constantly implies that everyone in high prevalence countries in Africa is at risk of being infected with HIV and that no one knows what their partner is up to. Therefore, anyone on Depo Provera or similar needs to understand the additional risk that the injectable version of the drug adds to their existing high level of risk.

If I was in a relationship with someone taking the injectable drug, or if I was taking it myself, I would not be waiting till January, till the World Health Organization decides “if evidence is now strong enough to advise women that the method may increase their risk of getting or transmitting HIV”. I’d find another contraceptive method, at least temporarily. People need clear and convincing advice. Why should they wait?

The New York Times reviews Dr Jacques Pepin’s ‘The Origins of Aids’, which aims to shed light on how rapidly expanding twentieth century public health campaigns may have been responsible for the spread of HIV and other blood-borne diseases in French and Belgian colonies from the 1920s onwards. Patients on such programs could get up to 300 injections in a lifetime. As a precedent, a schistosomiasis (bilharzia) campaign in Egypt that ended in 1980 infected more than half the recipients with hepatitis C, which is still more widespread in Egypt than in any other country in the world.

The book, ‘The Origins of AIDS’, is by Dr Jacques Pepin, whose papers on the subject have been discussed on my HIV in Kenya blog in the past. Starting 60 years before the disease was even noticed, the book aims to tie up some of the many mysteries about how a disease that is now said to be almost always transmitted sexually could have spread to become a pandemic, infecting over 20 million people in a handful of sub-Saharan African and another 15 million people throughout the rest of the world. 25 million are estimated to have died from AIDS.

The author himself admits that he may have inadvertently infected some of his patients because the process of ensuring that injecting equipment was sterile was often lacking. He was working on a schistosomiasis epidemic in the early 1980s, before HIV had been recognized. But it was when Pepin went on to work with HIV-2, HIV-1 being the more widespread and more deadly of the two, that the question of how a virus that was difficult to transmit sexually could become a (partly) sexually transmitted pandemic.

People with HIV-2 can live for a long time and it was only found in older people at the time he started working with it in Guinea-Bissau. This suggested that it was dying out, as it was not spreading among young, sexually active people. So Pepin sought an alternative mode of transmission that allowed HIV-2 to have once flourished, and then die out. He began to investigate various public health campaigns against syphilis, yaws, leprosy, TB and others, which went on until the 1960s. Notice, some of the groups targeted by such campaigns would have overlapped with those currently targeted by HIV campaigns, being sexually transmitted.

Pepin looked for evidence that blood-borne diseases other than HIV had been spread by injections, circumcisions and other skin breaking practices. He also noted the colonial public health programs’ keen interest in sex workers and various other practices that may relate to sexual behavior. But when the virus jumped from chimps to hunters, the whole process consisted of such low probability events that sexual transmission alone would never have allowed HIV to become a pandemic; it would have just died out, having only infected a handful of people.

This is where Pepin’s notion of an ‘amplifier’ comes in. He found that blood transmission of HIV is 10 times more efficient than sexual transmission. But the amplifier in colonial African countries was the public health campaigns, with their heavy use of injections. It was only later, once public health campaigns had spread the virus throughout many populations, that sexual behavior became responsible for further transmission.

Interestingly, Pepin says that sexually transmitted infection (STI) eradication campaigns ceased some time before the contribution of sexual transmission to the HIV epidemic increased. But in the Nairobi instance cited, where HIV prevalence went from 5% to 82% in three years, it seems possible that an STI eradication campaign may have played a part in spreading HIV among sex workers, rather than sexual behavior alone explaining the massive prevalence rate recorded in the mid 1980s. After all, HIV prevalence among sex workers, along with other STI rates, declined sharply after about 1986, and the downward trend continued well into the 1990s.

Again, when HIV spread to Haiti, Pepin notes that the virus was unlikely to have been spread very widely through sex alone. This time, he suggests as an amplifier a plasma donation center, which operated in the early 1970s. The process involves donating blood from which the plasma is extracted and the remainder is injected back into the donor. If unsterile equipment was reused this would risk spreading HIV and other blood-borne diseases. This route of HIV transmission has been well demonstrated in other countries and may still occur.

These blood products were exported to the US. Haiti was also well known as a sex-tourism destination, especially for gay sex, so this would have played a part. Anal sex, whether male to male or male to female, is a far more efficient transmitter of HIV than penile-vaginal sex. And thus, the earliest discovered victims of HIV and AIDS were men who had sex with men and hemophiliacs. The former are still at higher risk than those who don’t engage in anal sex; the latter are still at risk in countries where the safety of healthcare can not be guaranteed, such as all the medium and high prevalence countries in Africa.

Let us hope that the work that Pepin has started will prompt an investigation into the possibility that unsafe healthcare may still be responsible for HIV transmission in some resource-poor areas. Efforts to influence people’s sexual behavior, which go back many decades, starting with efforts to reduce STI rates and birth rates and continuing right up to the present, have had few successes, if any. But investigating the many cases of HIV infection where sexual contact is unlikely to have been responsible, or unlikely to have occurred, could present a far more effective, and less stigmatizing way of reducing HIV transmission.

[I have used this NY Times review to relate Dr Pepin’s research to other research into the relative contribution of non-sexually transmitted HIV to the current pandemic. Since writing the above, I have had the opportunity to read The Origins of Aids and have made some comments on the HIV in Kenya blog (hivinkenya.blogspot.com); more should follow once I’ve had time to read some of his sources.]

Although it is written in a somewhat anecdotal style, a recent article by Moses Okinyi raises some important points. Estimates of the relative contribution of unsafe medical injections to HIV epidemics in African countries range from the improbably low of less than 1% to the frighteningly high 25%. But what is most shocking is that there are only estimates, based on far too little data. This is an unacceptable situation thirty years into the HIV pandemic.

Okinyi notes the use of figures for HIV infections in children who have HIV negative mothers to build up some idea of the size of the problem. But many may be horrified just to hear that there are sizable numbers of HIV positive children with HIV negative mothers, the children’s HIV positive status often not being identified until years after they were infected because their mother happened to test negative.

The recently released film, Puncture, touches on some of the issues. A nurse is infected with HIV through a needlestick injury when working with a HIV positive patient. Things get interesting when the ensuing investigation reveals that there are syringes available that reduce the chances of such an injury and eliminate reuse of the device. Yet rivalry between producers of medical devices meant that the hospital was still using disposable syringes which carry a risk to the healthcare workers, and can also be reused.

Of course, the fact that syringes can be reused doesn’t mean that they are reused. But in countries where HIV prevalence is high and resources are scarce, it could be a temptation, even a necessity. Several Service Provision Assessment Reports have shown that many health facilities don’t have the equipment, supplies, procedures, even the training they need to prevent infection in healthcare settings.

The movie apparently (I haven’t seen it) takes an adversarial approach to the issue. This is unlikely to be helpful in developing countries, where eliminating such infections is the most important step, rather than pointing fingers at those thought to be ‘to blame’. There has been too much finger pointing already and it has been counterproductive.

However, people in high prevalence countries need to know how to avoid being infected with HIV and other blood borne diseases in healthcare and other settings, how to avoid transmitting these diseases and generally ensuring that the healthcare they and their family and friends receive is safe.

In addition to avoiding infection, recognition that HIV is not always transmitted sexually should reduce the stigma which has built up around a disease that is said by UNAIDS and the HIV industry to be 80-90% transmitted by unsafe heterosexual sex. In fact, the industry doesn’t really know the extent of non-sexual HIV transmission, despite their glib assurances.

Okinyi mentions a young HIV postive boy in Kenya who was probably infected through contaminated injecting equipment, or some other medical device. The boy’s mother is still HIV negative, though she would have risked being infected by her child through breastfeeding. It was only when the boy was diagnosed with TB that he was even tested for HIV. If his mother had been tested then and been found to be positive, it is likely that the whole issue of hospital transmitted HIV would never have been raised.

A lot of effort has been made to replace reusable syringes in resource poor countries but there is still a long way to go. And it’s not in the interest of those producing reusable (though nominally disposable) injecting equipment to advocate the use of something that is made by a competitor. Producers of medical devices, like pharmaceutical companies, make good use of their ability to influence what products doctors and other practitioners use most. Patient safety is only going to be a concern to them if it guarantees they increase their profits. If it cuts into their profits, they might prefer the issues to remain ignored (or strongly denied, as they are by UNAIDS).

Using estimates of HIV inefections in infants and young children tends to rule out the possiblity that they were infected sexually. Whereas, if any HIV positive person in high prevalence African countries is, or could be sexually active, it is generally assumed that they were infected sexually, regardless of the low levels of sexual risk they may have faced, or the high levels of non-sexual risk.

Whatever technologies may be available, ultimately the problems of hospital acquired and hospital transmitted HIV will continue until they are recognized as problems, rather than strenuously denied. This requires thorough investigation of conditions and practices in health facilities, with honest disclosure of findings. It will then be possible to estimate the relative contributions of sexual and non-sexual modes of transmission, and implement HIV prevention programs accordingly.

Allowing unsafe healthcare practices to continue, uninvestigated, would not be acceptable in Western countries. Nor would the use of substandard equipment and supplies that are known to increase risk to patients, healthcare workers and even the environment. So why are they acceptable to Western donors, who often contribute to such phenomena through providing the health aid money, and also deciding how it should be spent?

All the humming and hawing about injectable hormonal contraceptive, Depo Provera, must be very confusing to people who want to know whether they should discontinue using it, continue using it or get advice from a health professional. However, USAID have weighed in with the clear advice to continue using it.

Their brief communication concludes that “USAID does not believe that a change in contraceptive policy or programming is appropriate or necessary at this time”. I find this advice surprising. People who have the combined problem of avoiding conception and protecting themselves against sexually transmitted infections (STI) can always use a different contraceptive method (such as condoms), or combination of methods.

Therefore, people with the luxury of good advice and a wide range of contraceptive methods at their disposal should avail of those. But what about all the people to whom these are not available? They are the most likely to be using Depo Provera, as it is most frequently used by members of ethnic minorities in rich countries and by the general population if poor countries.

The worry is not just about HIV, that’s only one disease. But there have been known side effects relating to the use of Depo Provera since the 1990s. Concerns have even been raised about the use of the drug it contains far earlier than that. If Depo Provera is not generally used by middle class white people in rich countries, why is it still being promoted to non-white people in poor countries, given the long standing and serious concerns about its safety?

Someone has sent me rough calculations on how effective stopping the use of Depo Provera would be in reducing the risk of HIV transmission, compared to UNAIDS’ beloved male circumcision. Circumcising men only reduces the risk of women transmitting HIV to men by quite a small factor. But it substantially increases the risk of men transmitting HIV to women. On the other hand, stopping Depo Provera use reduces the risk of transmitting from men to women and from women to men.

As mentioned above, there are more health issues here than HIV, or even STIs or unplanned pregnancies. So why promote one HIV ‘prevention’ method that will almost certainly increase transmission to women (male circumcision), without reducing transmission to men that much, while also promoting a contraceptive method that increases transmission in both directions (Depo Provera, and perhaps other hormonal contraceptives)?

In developing countries there is also the issue of unsafe healthcare, the as yet unaddressed problem of reused injecting equipment. This may or may not be a factor in the association between injectable Depo Provera use and increased HIV transmission risk. As there have been no investigations of possible transmission of HIV or other blood-borne diseases in Africa through unsafe healthcare, perhaps USAID will also clarify this matter while they are considering Depo Provera (if they are still considering Depo Provera).