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Date: Tue, 8 Apr 2003 17:16:06 -0500
From: Africa Action <[log in to unmask]>
To: [log in to unmask]
Subject: Africa: Unsafe Health Care Spreading HIV
AFRICA ACTION
Africa Policy E-Journal
April 8, 2003 (030408)
Africa: Unsafe Health Care Spreading HIV
(Reposted from sources cited below)
This posting contains the executive summary of a new white paper
from Physicians for Human Rights, on the transmission of HIV in
Africa through unsafe medical care, including unsafe injections and
blood transfusions. The paper concludes that AIDS prevention
efforts need to take into account significant evidence that
transmission through unsafe medical care has been significantly
underestimated, and urgently recommends increased investment in
adequately protecting blood supplies, preventing re-use of needles
for injections, and taking other health care precautions that are
considered standard in developed countries.
While acknowledging that there is much legitimate debate over
precisely how much transmission occurs through these means, the
paper notes that even according to minimum estimates from the World
Health Organization, the HIV virus is transmitted to as many as
half a million people a year in developing countries through these
mechanisms rather than through sex. While critics say that focus on
these figures could divert attention from necessary prevention
measures aimed at safe sex, the PHR paper argues for increased
resources for safe medical care without reducing resources
for the safe-sex message.
The paper notes the double standard implicit in the denial of basic
principles of safe health care for developing countries. Among the
examples it cites is a recent finding in Bas Congo Province in the
DRC that only 42% of the blood that was transfused in the province
was screened for HIV. The study cited estimated that in this one
province of about 3.3 million people, blood transfusions alone led to
approximately 888 HIV infections in the first nine months of 2001.
In the first decade of the HIV pandemic, developed countries
stepped up medical care precautions, including blood screening,
reducing transmission through these means. Such measures, however,
have never been implemented systematically in many African and
Asian countries, while the medical establishment has downplayed the
problem.
Other resources on this topic inlude recent congressional hearings,
a new article in the March 2003 issue of the International Journal
of STD & AIDS, and an earlier posting on the same subject in the E-
Journal last October.
Congressional Hearings on Transmission of Global AIDS in
Africa, March 27, 2003
http://www.kaisernetwork.org/health_cast/
hcast_index.cfm?display=detail&hc=817
[type URL on one line]
Let it be sexual: how health care transmission of AIDS in Africa
was ignored, by David Gisselquist PhD1, John J Potterat BA2,
StuartBrody PhD and Francois Vachon MD
International Journal of STD & AIDS 2003; 14: 148-161
http://www.rsm.ac.uk/new/std148main.pdf
See also an earlier posting in the Africa Policy E-Journal on
the same subject at:
http://www.africaaction.org/docs02/hiv0210t.htm
+++++++++++++++++end summary/introduction+++++++++++++++++++++++
HIV Transmission in the Medical Setting:
A White Paper by Physicians for Human Rights
Full text (including footnotes) available at:
http://www.phrusa.org/campaigns/aids/who_031303.html
Executive Summary
Even as prevention programs aimed at sexual transmission require
greater funding, the high risk of HIV transmission in health care
settings requires immediate and sustained attention from national
and multilateral organizations involved in HIV/AIDS prevention
activities. Every year, because of violations of core aspects of
the right to health, at least half a million people - and possibly
many more - contract HIV through unsafe medical injections(1) and
blood transfusions(2). Throughout the developing world, health care
providers, health facility staff, patients, and the community at
large are placed at risk of contracting HIV because of a lack of
supplies, poor training, poor awareness about the danger of unsafe
injections, and lack of incentive to observe good practices.
A foundational principle of medical ethics is that physicians must
"first, do no harm." A central tenet of the right to health is
that health care must be safe. People in every country, rich and
poor, have the right to a health system that improves people's
health, not one that creates grave risks to health. Yet unsafe
medical injections and unsafe blood transfusions contribute
significantly to the greatest health crisis of our time, the
HIV/AIDS pandemic. Inadequate efforts by donors, multilateral
organizations, and the governments of impoverished countries
themselves to ensure safe health care for people in poor countries
suggest a tacit, widespread acceptance of a two-tiered health
system: health care must observe the highest standards in wealthy
countries, but not necessarily in poorer countries. Under human
rights law, health care must be safe in every country. Until the
discriminatory perception ends, unsafe medical injections and
unsafe blood transfusions will continue to contribute considerably
to the HIV/AIDS pandemic, as well as to the spread of other
bloodborne pathogens such as the hepatitis B and hepatitis C
viruses.
Discrimination against people living with HIV/AIDS is also fueling
the pandemic. The widespread inability of health care providers in
developing countries to implement universal precautions necessary
for them to protect themselves from contracting HIV from their
patients contributes to that discrimination. Without proper
training or adequate supplies, health care providers' often
reasonable fears for their own safety frequently have devastating
consequences. The fears can lead health care providers to refuse to
treat people infected with HIV, or to follow safety precautions
only for people they suspect are infected, thus contributing to the
stigma and isolation of people living with HIV/AIDS. This
discriminatory treatment of people living with HIV/AIDS violates a
core aspect of the right to health, everyone's right to access
health care on a non-discriminatory basis. Until universal
precautions become universally implemented, such discrimination
seems destined to continue.
Discrimination that HIV-positive people face in the health system
has lethal consequences. It discourages them from seeking health
care, such as treatment for opportunistic infections and
nutritional counseling, speeding people's passage from infection to
death. Discrimination in the health care sector and the stigma and
discrimination that people with HIV/AIDS face throughout society
also discourages people from seeking voluntary counseling and
testing services, which might reveal that they are HIV-positive.
Yet these services provide HIV/AIDS education and strategies that
enable people infected with the virus to take precautions against
transmitting the disease to others, and voluntary counseling and
testing services are the gateway to interventions that can improve
the health of people with HIV/AIDS. Every step towards ending
discrimination against people living with HIV/AIDS is a step
towards stopping the spread of the disease. Providing the training
and supplies to enable health care providers to adhere to universal
precautions, including injection safety, is one such step.
To assure people's human rights and to help slow the HIV/AIDS
pandemic, strong, immediate efforts must be made to improve the
safety of blood supplies and health care providers' adherence to
universal precautions, including safe injection practices.
Since the late 1980s, the World Health Organization (WHO) has not
emphasized the risks of HIV transmission in the health care
setting, though it has recognized the dangers of unsafe blood
supplies(3). Renewed interest in these risks has begun to surface
in the past several years. In late 2002, UNAIDS recognized
universal precautions and safe injection practices as important
interventions by including them for the first time in an estimate
of the cost of a global response to the HIV/AIDS pandemic(4). A
year earlier, the United Nations General Assembly Special Session's
Declaration of Commitment on HIV/AIDS urged the nations of the
world to implement universal precautions to prevent HIV
transmission in health care settings by 2003, and to expand access
to sterile injecting equipment by 2005(5).
The urgency to act to reduce the risks of transmitting HIV in the
health care setting does not suggest any lessening in the
importance of decreasing sexual transmission. Indeed, efforts to do
so must be scaled up significantly and urgently. Encouraging broad
recognition of the importance of universal precautions, including
injection safety, along with a renewed focus on blood safety, is
simply an attempt to open up another front in the war against
HIV/AIDS. The experience of Uganda demonstrates that it is possible
to educate people on the risks of infection through unsafe
injections while still achieving significant behavioral changes to
reduce HIV transmission through sexual behavior(6).
Unsafe medical injections
Unsafe medical injections are probably the most significant route
of HIV transmission in the medical setting(7). Medical injections
are procedures that pierce the skin and introduce a substance into
the patient for curative or preventative medical purposes,
including immunizations. The infections they cause each year will
lead to more than a million deaths from hepatitis B, hepatitis C,
and HIV/AIDS(8). Injections are unsafe when syringes are re-used
without being sterilized properly or at all. When a syringe is used
on an HIV-positive patient, that syringe can be contaminated with
HIV-infected blood, which can then be passed on to the next person
if re-used. The danger is especially great because of the
extensive, often unnecessary and irrational use of injections in
developing countries. Studies have estimated that as many as 70-90%
of injections in developing countries are unnecessary(9). Re-use of
injection equipment is especially high in Asia and sub-Saharan
Africa, where syringes may be re-used as frequently as 50% or more
of the time(10).
According to a very recent model, unsafe injections cause 260,000
HIV infections globally every year(11). This number may be
understated since it is based on a lower proportion of unsafe
injections in Africa than probably exists(12); it uses an arguably
low estimate of the efficiency of HIV transmission through unsafe
injections(13), and; studies from Africa indicate a greater
importance of HIV transmission through unsafe injections than the
model generates(14). A large study in South Africa found high
levels of HIV in children ages 2-14, about 70% of which could not
be explained by mother-to-child transmission(15). Low levels of
sexual experience for these children suggest that many of these
infections may have been caused by unsafe injections and other
modes of medical transmission. Several studies have shown
significant HIV levels among adults who reported never having any
sexual experience, or who reported having had only one sexual
partner, who was HIV-negative(16). Also, a data-driven model found
that sexual activity can explain only about one-third of the
epidemic's growth(17). This suggests that a relatively high
proportion of infections may be attributed to unsafe injections and
other forms of transmission in the health care setting, including
blood transfusions and modes of transmission whose importance is
not yet be well understood.
Along with transmitting HIV, unsafe injections are responsible for
significant proportions of hepatitis B and C infections. Every
year, about 8-20.6 million people become infected with hepatitis B
and 2.0-4.7 million with hepatitis C because of unsafe medical
injections(18). Of those people infected with hepatitis B and
hepatitis C every year through unsafe injections, an estimated 1.2
million will die from these infections(19).
Inexpensive technology exists to make injections safe, in
particular single-use and auto-disable syringes. Single-use
syringes are meant to be disposed of after one injection.
Auto-disable syringes have the added advantage of being
automatically altered so that they cannot be re-used. Along with
the availability of this equipment, health care providers and the
general public need to be educated about the dangers of unsafe
injections, as well as about the appropriate use of injections, so
as to reduce the number of unnecessary injections. Annual cost
estimates for a global injection safety initiative range from about
$300 million to $900 million(20).
The public needs to be encouraged to insist that their health care
providers always use a new, sterile needle and syringe. Because
syringes will be used only once, the number of syringes disposed of
will increase, at least until health care worker training and
public education reduces the number of unnecessary injections. This
means that safe injection waste management will be particularly
important. The potentially hazardous waste must be contained in
safety boxes and destroyed to avoid putting health facility staff
and community members at unnecessary risk of needlestick injuries
and bloodborne infections.
In 1999, the WHO-sponsored Safe Injection Global Network (SIGN)
became the central organization in advocating safe injections(21).
UNICEF, the U.S. Agency for International Development (USAID), and
others have contributed to increased use of auto-disable syringes
in immunization and family-planning programs(22). A "bundling"
policy for immunizations encourages donors and lenders who finance
vaccines to also finance auto-disable syringes and safety boxes for
their disposal(23). However, comparable progress in using safe
injection equipment has not been made for curative injections,
which account for the vast majority of medical injections(24).
Recognizing the important connection between unsafe medical
injections and HIV/AIDS would likely accelerate efforts to ensure
injection safety for curative injections. At present, most HIV
prevention initiatives fail to give adequate attention to the risks
of contracting HIV through medical injections. Some countries,
though, such as Uganda and Senegal, have included or are beginning
to include injection safety as part of their HIV/AIDS
strategies(25).
Multi-dose vials
Multi-dose vials also have been implicated in transmitting
bloodborne infections, including hepatitis B, hepatitis C, and
HIV(26). Multi-dose vials contain multiple doses of an injectable
substance, meaning that the health care provider will insert
syringes into the vial multiple times. Both the high levels of
syringe re-use and the high prevalence levels of HIV increase the
possibility that multi-dose vials could be responsible for
transmitting HIV when the vials are contaminated with the virus.
These risks can be eliminated by replacing multi-dose vials with
single-dose vials. Immunization programs that are financed by
national governments might be unable to afford single-dose vial use
without international assistance.
Sterilization of equipment
Even if syringes are never re-used, some instruments, such as
scissors and forceps, will continue to be used on multiple
patients. This makes it critical that health care providers are
trained in proper sterilization techniques and have the necessary
equipment, such as steam sterilizers and time-steam
saturation-temperature indicators, to properly sterilize these
instruments and verify their sterility.
Blood transfusions
Blood transfusions are another significant mode of HIV transmission
in the health care setting. They appear to be responsible for 5-10%
of new HIV infections(27). According to WHO's Regional Office for
Africa, only about 75% of blood transfused in Africa is screened
for HIV, with far lower proportions screened for hepatitis B and
hepatitis C(28). As of 2000, most countries in Africa did not have
safe blood policies, though WHO and other organizations have been
working with countries to help them develop such policies(29).
It is well within the capacity of African nations to implement
effective blood transfusion policies. Countries including South
Africa, Zimbabwe, Namibia, and Uganda have achieved a safe blood
supply(30). Key elements of a safe blood policy include careful
selection of voluntary, unpaid blood donors, and health
infrastructure that includes blood banks, training for donor
recruiters, counselors, blood collectors, laboratory staff, and
quality managers, blood test kits and reagents, a robust supply
chain, and refrigeration capacity.
The potential for blood transfusions to cause large numbers of HIV
infections is apparent from the epidemic in Henan Province, China,
where as many as one million or more people became infected through
blood selling practices in the 1990s, which involved unsterile
blood donation procedures(31). China has included an investment of
about $115 million in its five-year plan to build more blood
collection stations, though increasing the number of voluntary
blood donors is also critical to improving blood safety in
China(32). India too has taken measures to improve blood safety,
following the identification of transfusions as a significant cause
of HIV transmission there(33).
Universal precautions
To protect health care providers, as well as to prevent HIV and
other infectious diseases from being transmitted from health care
providers to their patients, universal precautions must be
implemented. Universal precautions are infection control measures
aimed at preventing the transmission of HIV and other pathogens in
blood and other body fluids in the health care setting. They
include safe injection practices and measures to create physical
barriers such as wearing gloves, goggles, and other protective
gear. UNAIDS has estimated the cost of implementing universal
precautions in all countries with an adult HIV prevalence of more
than 1% at about $500-600 million in 2003, rising to about $1.1-1.2
billion by 2007(34).
The greatest risks for occupational infections appear to come from
needlestick injuries(35). One study estimated that the risk of
occupational acquisition of HIV for surgeons practicing in Zambia
was fifteen times that of their Western colleagues, primarily due
to the high HIV prevalence in Zambia. That study found that most
injuries to surgeons occurred through needlestick injuries caused
by suture needles(36). Replacing sharp suture needles with blunt
needles could prevent many injuries caused during suturing(37).
Universal precautions are frequently not followed in both
sub-Saharan Africa and much of Asia because of both a shortage of
supplies and inadequate training. Dangerous diagnostic equipment,
such as nonretracting finger-stick lancets and glass capillary
tubes, is often used in developing countries, in spite of the fact
that safe alternatives exist(38).
Healthy health care providers are an absolute necessity for a
strong health care system and universal precautions will contribute
to protecting their well-being. Many countries, particular in
Africa, are facing severe shortages of health professionals and
other health care providers. Minimizing reductions in the health
care workforce by improving occupational safety through the
implementation of universal precautions is an important step in
retaining qualified and experienced staff.
Implementing universal precautions will help strengthen health care
systems. Many countries, particular in Africa, are facing severe
shortages of health professionals and other health care providers.
Universal precautions can help save their lives. The potential for
a fast, significant impact on the HIV/AIDS pandemic should help
convince policymakers to seriously address the risks of HIV
transmission in health care settings. It is critical that they act
now, for the dangers of unsafe injections and failing to implement
universal precautions increase as HIV prevalence increases. The
longer countries wait to address these dangers, the greater the
amount of HIV transmission in health care settings will occur.
Call to action
The number of people who become infected with HIV through unsafe
injections and other medical procedures is a controversial
question. While the discussion of the number of people who become
infected through these modes is one that should take place,
Physicians for Human Rights urges WHO, UNAIDS, national health and
HIV/AIDS organizations, donors, and others who are responding to
the pandemic to focus their energies not on debating numbers, but
on implementing programs and initiating new, life-saving policies
without delay. In particular, PHR calls upon the international
community to live up to its pledge in the Declaration of Commitment
on HIV/AIDS to implement universal precautions in all nations by
2003. PHR further calls upon the international community to
endeavor to ensure that all health facilities have safe injection
equipment by the end of 2003, given the significance of HIV
transmission through unsafe injections and the relative ease with
which this problem can be solved(39).
+++++++++++++++++++++Document Profile+++++++++++++++++++++
Date distributed (ymd): 030408
Region: Continent-Wide
Issue Areas: +health+ +economy/development+
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