How people can stop HIV transmission during healthcare
…the message that other people’s blood is extremely dangerous is not yet appreciated in many developing countries.
– Mark Kane, 1998[i]
Because public health managers in countries with generalized epidemics have failed to stop HIV transmission through common blood exposures in healthcare and cosmetic services, it is up to people who are at risk to protect themselves and to demand safe care and services. This is doable with some proven strategies, although application of these strategies will vary from place to place, and from one person to another.
How to protect yourself: Demand investigations
One of the most important things that people can do to protect themselves is to work together to demand investigations of unexplained HIV infections. Unexplained infections are warnings. If nobody investigates smoke, the house might burn down. When an HIV-positive child has an HIV-negative mother, or a wife is HIV-positive with no sexual partners except an HIV-negative husband, these infections are evidence that some clinic or hospital may be infecting others in the community. If no one investigates – testing to find others who have been infected, and to identify the procedures that were responsible – outbreaks can continue with hundreds or thousands of infections (as in Russia, Romania, and Libya).
Without investigations that can identify dangerous clinics and procedures, trying to stop transmission of HIV through healthcare by advising healthcare workers to be careful is like trying to shoot bats on a moonless night. Most healthcare workers think that what they do is safe enough, even though it may not be. Investigations alert healthcare workers to unexpected dangers. And publicity surrounding investigations alerts the public to demand safe care.
In countries where investigations uncovered hospital-based outbreaks, findings from these investigations guided and motivated changes that stopped nosocomial HIV transmission. In Russia, testing after 1989 discovered no new hospital-based outbreaks, although HIV transmits among IDUs. As of 2005, Romania had a concentrated epidemic with less than 0.1 percent HIV prevalence among adults – one of the lowest rates in Europe.
Investigations do not challenge anyone’s confidentiality. Whoever is managing an investigation invites people to come for HIV tests based on their attending specific clinics or hospitals during specified periods. No one is required to go for tests, and test results can be confidential. To be accountable to the public, and to help people in the community assess their risks during healthcare, investigators should report their findings in detail – including the number of infections, the ages of those infected, the hospitals and clinics where they were infected, the procedures that transmitted HIV, and so on. Investigators can report such information without disclosing who was infected.
For families with unexplained HIV infections, investigations not only provide explanations, but also bring assistance. In Libya, for example, the government arranged to treat HIV-positive children. Investigations also protect breastfeeding mothers of HIV-positive children and sexual partners of HIV-positive adults by warning them that they are exposed to HIV.
Mobilizing the media, politicians, and courts to achieve investigations
In Russia, government health officials initiated the investigation. In Romania, doctors took the lead. In Libya, parents of infected children pushed the government to investigate.
Public demands for investigation may have to overcome objections from ministries of health, international agencies, and health aid programs as well as from hospitals and clinics subject to investigation. To do so, people can work together to mobilize support through the media, churches, and other civil society organizations. Politicians and their friends and families go for healthcare, so that politicians share the public’s concerns about unsafe care. Thus, central or sub-national governments may order ministries or departments of health to investigate. In some countries, courts may be able to order investigations.
When President Yoweri Museveni of Uganda addressed the first AIDS Congress in East and Central Africa in Kampala in 1991, he noted that ‘hundreds of children have become infected through the use of unsterilized syringes’ in Eastern Europe, and wondered, ‘What is happening in our countries, where facilities are worse!’ He illustrated his concern with an anecdote:[ii]
I was told a story the other day of a woman taking her child to the hospital…When she got there, the nurse on duty told her that the child needed an injection, but the woman was worried that the syringe might be unsterilized. The nurse said to her, ‘For you, madam, we shall use a disposable syringe, but we don’t bother to use them on those other common people.’ Now, this kind of attitude is completely at variance with medical ethics…
Museveni acknowledged that healthcare providers in Africa worked ‘under very difficult conditions,’ but challenged them to deliver safe care.
Given Museveni’s awareness of investigations in Europe, and his demand that healthcare workers deliver safe care, it is noteworthy that none of the many unexplained HIV infections that have been reported in Ugandan children has led to an investigation. The public and media have not been alert to demand investigations.
No fault investigations?
The community’s interest in promoting investigations of unexplained and possibly nosocomial infections is to find out what happened, so that nosocomial transmission can be stopped. Efforts to prosecute or to sue healthcare staff may motivate legal or other strategies to obstruct investigations. One way to avoid such problems may be to release healthcare managers and providers from liability as long as they cooperate with investigators, so that those who have infected patients through carelessness will not be charged with crimes or face civil suits. South Africa’s Truth and Reconciliation Commission, which investigated race-related crimes during the apartheid era, provides a model for no-fault investigations.
In Libya and Kazakhstan, investigations that uncovered nosocomial outbreaks led to criminal charges and convictions against healthcare staff. In Libya, convictions made scapegoats of foreign healthcare workers. In Kazakhstan, courts gave harsh punishments to front-line healthcare staff, but suspended sentences to senior managers. In both cases, many who contributed to the culture of carelessness, including WHO and UNAIDS staff in Geneva, were completely out of the picture.
But what happens to those who have been infected through healthcare errors if a country goes for no-fault investigations? In many countries, governments already provide free antiretrovirals for AIDS patients. Even so, governments, churches, and other private groups should consider offering more support to children and others infected through healthcare errors. Even without immunity protecting healthcare providers from civil suits, it is unlikely that more than a small minority of victims would be able to prove who was responsible and to collect compensation.
How to protect yourself: Ask for POST (patient-observed sterile treatment)
In much of Africa and Asia, efforts to promote standard precautions have not ensured safe healthcare in the formal sector. Furthermore, people receive much of their healthcare and cosmetic services from providers in the informal sector, who are beyond the reach of professional education and regulation. Thus, patients and clients would be well-advised to look out for their own safety in both formal and informal settings.
To do so, patients and clients can ask service providers to follow practices that will show that instruments are sterile, and that there is no risk to transmit HIV. For example, when going for injections, patients can ask to see providers take new disposable syringes and needles from sealed plastic packages, and take what is injected from single-dose vials. An acronym that describes these and other similar practices is POST, for patient-observed sterile treatment.[iii]
For some procedures, such as drilling and filling a tooth, the POST practices that are required to demonstrate that everything is sterile may be more complicated than for injections. Some POST practices might add cost. On the other hand, costs may be lower for some safer practices, such as oral or no medication instead of an injection.
POST practices have already started
Even though the POST strategy has not been systematically promoted anywhere (and few people use the acronym), patients, clients, and service providers have already adopted a variety of practices that fit this strategy. When I visit countries with generalized epidemics, or talk with people who have lived there, I often ask what people do to protect themselves from blood exposures. Awareness varies, as do strategies.
During a visit to Mwanza, Tanzania, in 2000, I found that nurses gave pregnant women a list of items to bring for delivery – including plastic gloves, syringe and needle, and razor blade – to protect both healthcare workers and patients. A study in Uganda in the mid-1990s observed that inpatients bring ‘a saucepan, cooking stove and fuel’ to the hospital. ‘At the surgical ward where most patients are receiving over four injections daily,’ their attending family or friends ‘would boil the equipment once in the morning and later in the evening.’[iv] (Although I do not recommend this strategy if other options are available, it illustrates public awareness of risks and patient initiative to ensure safe care.)
Consumer concern about safety has led to more use of disposable syringes. A study of injection practices in 80 clinics in Vellore, India, in the 1990s found that most of them routinely reused syringes and needles without sterilization, and only one patient brought a disposable syringe for own use.[v] From 1995 to 2005, the number of glass syringes sold in India fell by more than 80 percent, while sales of disposable plastic syringes increased by over 500 percent.[vi] In a study of injection practices in Ethiopia in 2002, 48 percent of patients brought new disposable syringes for healthcare workers to use to administer injections.[vii]
Surveys of injection practices in Uganda in 1993 found that over 60 percent of households brought their own syringes from home. This did not ensure safety because families did not always sterilize them before reuse.[viii] Clinics (presumably) used patients’ often unsterile syringes to withdraw vaccines and medicines from multidose vials. In this case, ignorance about HIV’s ability to survive in syringes for weeks, and to go from syringes to multidose vials, left people with unrecognized risks.
In India, all barbers I visited in 2005 had shifted from a cut-throat razor (a specialized knife) to a tool that accepts a half-razor as the cutting edge. Each client brings a new razor, or the barber takes one from his stock of new razors. In DRC, people going for haircuts reportedly bring their own scissors and razors. On the other hand, a mother I spoke with in Botswana in 2004 reported that the barber who shaved her young child’s head, and who often nicked heads and drew blood, reused instruments without sterilization on child after child. She had not been aware that this was a danger until we talked about it.
Options to promote POST practices
In much of Africa and Asia, people access most healthcare as outpatients, and pay for much of their care from their own funds, and this is even more so for the poor than for the rich.[ix] In such situations, healthcare customers can ask for safe services, i.e., for POST. However, many people, including especially those who are poor or have less education, may be intimidated, and may find it difficult to request POST practices. But there are ways that POST can succeed even if most patients are intimidated.
First, in situations where providers feel that they are competing for customers, providers might be worried that they will lose customers if they do not accommodate patients’ concerns about safety. Thus, providers may adopt POST practices even if only a small minority of their clients is brave enough to ask.
Second, some providers – such as mission hospitals or public clinics – might adopt POST practices not only as a strategy to supervise their own health staff to ensure that procedures are safe but also as an educational device. For example, providers giving an injection with POST practices could explain to patients what they are doing and why, and they could encourage patients to insist on similar POST practices during future healthcare and cosmetic services from other providers.
Third, people concerned about patient safety may be able to promote POST practices through civil society organizations that do not provide healthcare, such as newspapers, private radio shows, unions, churches, and local councils. This is important, because organizations that provide healthcare might not want to educate and empower patients to recognize and protest dangerous practices. In Thailand in the early 1990s, Empower, a union of sex workers, warned sex workers about risks from unsafe injections. Companies and unions that arrange healthcare or health insurance for workers have an interest not only to protect workers from nosocomial infections, but also to avoid having to pay for AIDS care.
Organizations that promote POST could prepare educational materials for the general public as well as for providers of healthcare and cosmetic services. These materials could include, for example, posters illustrating POST practices for injections, tattoos, and other procedures for service providers to display in their waiting rooms.
Why the public might soon demand safe healthcare
More HIV tests
Through 2001, not more than about 5 percent of Africans who were HIV-positive were aware of their infections (see Chapter 7). Because HIV prevention messages focused on sex, people without high-risk sexual behaviors were even less likely to seek tests and to discover their HIV infections. Limited HIV testing thus contributed to public ignorance of unexplained and possibly nosocomial infections.
From 2001, two developments brought a major increase in HIV testing in countries with generalized epidemics. The first was the extension of programs to prevent mother-to-child (vertical) transmission by giving antiretroviral drugs to HIV-positive pregnant women and to their babies. In 2001 the UN General Assembly Special Session on HIV/AIDS set goals to reach 80 percent of pregnant women with HIV testing by 2010, and to reduce mother-to-child transmission by 50 percent.[x] In 2001, only about 1 percent of pregnant women in Africa received counseling to prevent mother-to-child transmission. By 2007, an estimated 34 percent of HIV-positive pregnant women in Africa, 32 percent in the Caribbean, and 22 percent in Asia received antiretroviral drugs to block mother-to-child transmission.[xi]
The second development was the commitment by WHO, donors, and member governments to deliver antiretroviral drugs to all people with AIDS in low- and middle-income countries. In 2003, the WHO established the 3 by 5 program – to put 3 million people in low- and middle-income countries on antiretroviral treatment by 2005. From 2001 to December 2007, the estimated proportion of Africans with HIV infection and severely weakened immune systems that was taking antiretroviral drugs increased from 1 percent to 32 percent, reaching an estimated 2.1 million people.[xii]
These two programs broke the logjam on HIV testing. Whereas most AIDS experts during the 1990s showed little interest in extending testing in countries with generalized epidemics, more and more AIDS experts after 2001 agreed that testing was central to HIV prevention. In 2003, Kevin De Cock, who later became the head of WHO’s HIV/AIDS Department, argued that ‘universal voluntary knowledge of HIV serostatus should be a prevention goal and that facilitation of HIV testing is central to responding to the epidemic in Africa.’[xiii] In 2004, health facilities in Botswana began to administer HIV tests routinely to all people who sought healthcare, giving them the option to refuse. In the same year, WHO and UNAIDS endorsed routine testing, often described as opt-out or provider-initiated testing. Among countries with generalized epidemics, almost half of the governments that answered a WHO questionaire in 2007 reported that they were recommending provider-initiated testing.[xiv]
By 2003-07, national surveys in some African countries found that more than 20 percent of HIV-positive adults had been tested and had received their test results, showing a large increase over the situation just a few years earlier. With donors and governments promoting tests, the percentage of HIV-positive people in generalized epidemics who know they are infected is likely to continue to show large increases over the next 3-5 years.
With more testing, and especially with routine or opt-out testing during healthcare, many people who know that they had no sexual risks for HIV will find they are HIV-positive. More HIV-negative mothers will learn that a child is HIV-positive. This will increase the possibility for a breakthrough in public awareness of nosocomial risks in their communities.
Awareness to action?
In Nigeria in 2006, after newspapers picked up the story of an infant infected from transfused blood, the governor of the state fired the head of the hospital that transfused the blood.[xv] On the other hand, there was no outrage and no investigation in South Africa in 2003 when The Sowetan reported an HIV-negative mother with an HIV-positive child who had never received a blood transfusion.[xvi] The case was treated as an isolated incident. Neither the media nor the public demanded tests for other children who had attended suspected health facilities, and there was no such investigation.
The ability of an outraged public to force changes to make blood transfusions safer demonstrates what can be achieved when the public becomes aware of the much more common and thus much greater threat from trace amounts of blood on reused instruments. Few people in countries with generalized epidemics are aware of the large hospital-based outbreaks of HIV infection among children caused by reused instruments in Russia, Romania, and other countries. Even fewer see those outbreaks as relevant to their communities.
Awareness will have to overcome misinformation. Health experts have not warned – and have even misinformed – the public about how long HIV survives in trace amounts of blood outside the body, and how easy HIV transmits through instruments reused without sterilization. Only 59 percent of senior secondary students in Nigeria identified sharing syringes and needles as a risk to transmit HIV,[xvii] and 28 percent of South African military recruits did not know that sharing injection equipment was a risk for HIV infection.[xviii] In India, sex workers interviewed in 2005 reported standing in line for tattoos, given without changing or cleaning needles or inkpots between clients.[xix] The women thought that was safe, because they believed that HIV survived only seconds outside the body.
When the public is alert to risks in blood exposures, they can find ways – talking to reporters, challenging politicians, going to court, whatever it takes – to demand investigations of unexplained HIV infections, and to ensure that healthcare managers and providers respect demands for safe care. Once healthcare personnel are motivated – by public accountability – technical and organizational changes required within the healthcare system to ensure that healthcare does not transmit HIV will fall into place. All parts of this solution, including information about risks, outrage, accountability, and healthcare system response are local.
Women on the front lines
Making HIV tests a routine part of antenatal care puts women on the front lines to face HIV-related stigma. Millions of women in Africa and India will soon learn during antenatal care that they are HIV-positive. Women who know they are infected can protect their newborn children and sexual partners, and can seek treatment for themselves. However, discovering their infections can also create problems for them. Based on information from recent surveys (Chapter 7), more than half of the husbands will be HIV-negative. To help women who test HIV-positive to retain the trust, love, and support of their families and friends, it is crucial that women’s groups, churches, and other organizations step forward to educate the public that an HIV-infection is not a reliable sign of sexual behavior.
Stopping generalized HIV epidemics
Will public demands for safe care stop generalized epidemics?
When public demands for investigations and safe practices stop HIV transmission through healthcare and cosmetic services, many HIV infections will be prevented. How many? No one knows. But it may be enough to stop generalized epidemics. Notably, no country that has investigated unexplained HIV infections to uncover a nosocomial outbreak has a generalized epidemic. Similarly, no country that enforces standard precautions – sterilization of reused invasive instruments – has a generalized epidemic.
Insofar as the response to HIV leads to more reliable sterilization of reused instruments in healthcare and cosmetic services, the gains in health go far beyond HIV. Hepatitis B and C viruses infect many more people than does HIV. Ebola and other viral hemorrhagic fevers are a continuous threat. But beyond these, other lesser-known and unknown pathogens spread through reused, unsterilized instruments.
Understanding and stopping generalized epidemics
In several countries in Southern Africa, the chance that an average woman will acquire an HIV infection at some time in her life is well over 50 percent. In many other countries and cities in Southern and East Africa, women’s lifetime risk for HIV infection exceeds 25 percent. If a similar disaster were occurring in North America or Europe, the public would demand that their government do whatever is necessary to understand the disaster and to stop it. This has not happened in Africa.
The investigations and research that are required to understand how HIV transmits so much more readily in some countries than in others are standard and easily doable – tracing infections to their sources, to specific sexual partners and to particular clinics, hospitals, or blood exposures. The primary obstacle to doing so appears to have been conflict of interest on the part of medical professionals – researchers, managers, and providers – who have not wanted to find HIV transmission through healthcare.
While it is discouraging that international agencies and foreign-funded health aid programs have not promoted or supported the investigations and research that are required to explain generalized HIV epidemics, it is probably best to simply accept it is so, and to get on with the task. Foreign experts and their families are not the ones dying from the epidemic. They carry their own syringes in Africa, and they avoid healthcare they know is not reliably safe.
When a car is heading into a crowd, the people who are in front of the car are the ones at risk, and they are the ones who have to move. By the same logic, it is up to people in countries with generalized epidemics to demand that their governments arrange the investigations and research required to understand and to stop their countries’ epidemics.
Investigating and tracing HIV infections to sexual partners and blood exposures could be expected to give a good indication about what is happening within 6-12 months. Such research is likely to lead to one of two findings. One possible finding is that blood exposures account for much of the difference between generalized vs. concentrated HIV epidemics. That would ‘solve’ generalized epidemics.
The other possible finding is that blood exposures account for some infections, but not enough to explain the difference between generalized and concentrated epidemics. In this case as well, the proposed investigations can be expected to show what drives generalized epidemics. Some experts suppose that men and women with new HIV infections are highly infectious, and account for most heterosexual transmission. Is it so? Others suppose that young women are acutely susceptible to HIV infection during first coitus. Is it so? The verisimilitude of these and other hypotheses could be determined in a matter of months by tracing infections to their sources. Better late then never.
Better understanding of the modes of HIV transmission in countries with generalized epidemics will allow people to protect themselves more effectively. Better information will also guide public health managers to address the most important risks with more focused programs that could slash HIV transmission. In effect, public health experts would be able to draw a red line around the epidemic – to say with confidence that this is how big it will be, and we can control it. That would allow governments and aid programs finally to cap budgets and attention to HIV, and to turn again to other issues.
[i] Kane M. ‘Unsafe injections’, Bull WHO, 1998, 76: 99-100.
[ii] Museveni YK. What is Africa’s Problem. Minneapolis: University of Minnesota Press, 2000. pp. 254-5.
[iii] Gisselquist D, Friedman E, Potterat JJ, et al. ‘Four policies to reduce HIV transmission through unsterile health care’, Int J STD AIDS, 2003, 14: 717-22.
[iv] Birungi H. ‘Injections and self-help: Risk and trust in Ugandan health care’, Soc Sci Med, 1998, 47: 1455-62. p. 1461.
[v] Lakshman M, Nichter M. ‘Contamination of medicine injection paraphernalia used by registered medical practitioners in south India: An ethnographic study’, Soc Sci Med, 2000, 51: 11-28.
[vi] Personal communication from Pardeep Sareen, Hindustan Syringes and Medical Devices, 30 December 2005.
[vii] Priddy F, Tesfaye F, Mengistu Y, et al. ‘Potential for medical transmission of HIV in Ethiopia’, AIDS, 2005, 19: 348-50.
[viii] van Staa A, Hardon A. ‘Injection practices in the developing world: A comparative review of field studies in Uganda and Indonesia’. Geneva: WHO, 1996. Doc. no. WHO/DAP/96.4.
[ix] Berman P. ‘Organization of ambulatory care provision: A critical determinant of health system performance in developing countries’, Bull WHO, 2000, 78: 791-802.
[x] UN General Assembly. ‘Declaration of Commitment on HIV/AIDS, 2 August 2001.’ New York: UN, 2001. Doc. no. A/Res/S-26/2.
[xi] WHO. Towards Universal Access: scaling up priority HIV/AIDS interventions in the health sector, progress report June 2008. Geneva: WHO, 2008.
[xii] WHO. The Health Sector Response to HIV/AIDS: Coverage of Selected Services in 2001: Preliminary Assessment. Geneva: WHO, 2002; WHO. Towards Universal Access.
[xiii] De Cock KM, Marum E, Mbori-Ngacha D. ‘A serostatus-based approach to HIV/AIDS prevention and care in Africa’, Lancet, 2003, 362: 1847-9. p. 1847.
[xiv] WHO. Guidance on provider-initiated HIV testing in health facilities. Geneva: WHO, 2007; WHO. Towards Universal Access.
[xv] Anaele A. ‘Lagos University Teaching Hospital HIV baby abandoned in ward’, Daily Sun (Lagos), 27 August 2006. Available at:
http://uqconnect.net/signfiles/Archives/SIGN-POST00363.txt (accessed 12 September 2007); ‘Lagos Nigeria: Crackdown on dodgy blood banks’, IRIN, 28 July 2006. Available at:
http://uqconnect.net/signfiles/Archives/SIGN-POST00359.txt (accessed 12 September 2007).
[xvi] Mabena K. ‘Mystery over HIV baby’, The Sowetan, 8 January 2003.
[xvii] Fawole OI, Asuzu MC, Oduntan SO. ‘Survey of knowledge, attitudes and sexual practices relating to HIV infection/AIDS among Nigerian secondary school students’, Afr J Reprod Health, 1999, 3 (2): 15-24.
[xviii] van der Ryst E, Joubert G, Steyn F, et al. ‘HIV/AIDS-related knowledge, attitudes and practices among South African military recruits’, S Afr Med J, 2001, 91: 587-91.
[xix] Correa M, Gisselquist D. HIV from Blood Exposures in India – An exploratory study. Colombo: Norwegian Church Aid, 2005.