For more than 30 years, international and foreign organizations and experts have advised Africans to ignore an undetermined number of HIV infections from health care. The last section of this chapter considers and critiques reasons for giving such bad advice – what were people thinking?

1984-86: Not investigating unexplained infections in children

During June-August 1985, researchers at Mama Yemo Hospital in Kinshasa, Zaire (currently the Democratic Republic of the Congo [DRC]) used newly-developed HIV tests to test in-patient children aged 2-24 months and their mothers for HIV.[1] Sixteen (6.2%) of 258 children were HIV-positive with HIV-negative mothers. Five of the 16 had received a blood transfusion. “For children with HIV-negative mothers, medical injections appeared to be the most important risk... Injections are often administered in dispensaries which reuse needles and syringes yet may not adequately sterilize their injection equipment.”

During 1984-86, researchers in Kigali, Rwanda, tested mothers of 76 HIV-positive children with AIDS aged 1-48 months. Fifteen (20%) of 76 mothers were HIV-negative.[2] Only 6 of the 15 children with HIV- negative mothers had received blood transfusions.

If such unexplained infections had been found in children in the US, Belgium or France (the countries that paid for the research), parents, media, politicians, and health officials would have demanded investigations. Governments of both DRC and Rwanda chose not to investigate, which was their mistake. But that does not excuse the failure of foreign funders and researchers to recommend investigations to protect public health.

The research team in DRC recommended unspecified “public health measures” to prevent HIV transmission through injections and blood transfusions.[1] Researchers in Kigali recommended boiling or bleach to de-contaminate reused syringes.[3] But without investigations, such recommendations were unguided – there was no way to zero in on the errors that infected patients – and the public remained ignorant about what was happening and about bloodborne risks.

Only months after researchers reported unexplained infections in children in Mama Yemo Hospital in DRC, four of the same experts published an influential overview of AIDS in Africa. They expected bloodborne risks to continue: “one cannot hope to prevent reuse of disposable injection equipment when many hospital budgets are insufficient for the purchase of antibiotics.”[4] Two authors of that overview led the international response to HIV/AIDS for 17 of the next 22 years: Jonathan Mann led WHO’s HIV/AIDS programs during 1986- 90; and Peter Piot led UNAIDS during 1996-2008.

In 1988, experts who had reported unexplained infections in children in Kigali published an overview of healthcare risks for HIV in Africa.[3] They expected continuing unknown numbers of HIV infections from health care: “The importance of medical injections in the epidemic of HIV infection seems to differ from one area to another.” But they did not want people to be afraid: “The risk of HIV contamination is low, if any, and should not compromise the immense benefit that widespread immunization campaigns have on children’s health.”

1991-93: Safe care for UN employees, not for African children

After investigations in Russia and Romania in 1988-90 found health care had infected hundreds to more than a thousand children with HIV (Chapter 2), WHO in 1991 arranged for hospitals in four countries in Africa – Rwanda, Tanzania, Uganda, and Zambia – to test inpatient children aged 6-59 months and their mothers for HIV. WHO reported combined data from the four countries. Sixty-one (1.1%) of 5,593 children were HIV-positive with HIV-negative mothers. Only three of the 61 had been transfused. At least four more children got HIV within three months after leaving the hospital. When reporting these 65 unexplained infections, WHO’s Global Programme on AIDS assured: “Based on these studies, the risk of… patient-to-patient transmission of HIV among children in health care settings is low.”[5] That statement says more about WHO’s double standard for Africa than about risks to get HIV from health care in Africa.

About the same time that WHO’s Global Programme on AIDS was assuring Africans they did not need to worry about getting HIV from health care, WHO was giving a different message to United Nations (UN) employees. WHO’s 1991 booklet, AIDS and HIV Infection: Information for United Nations Employees and Their Families, advised employees[6] "…living or traveling in areas where the level of medical care is uncertain [to]… take special precautions to avoid HIV transmission via blood... The WHO medical kit contains… syringes and needles in case staff need to have blood taken or receive an injection or vaccination while traveling… If you are not carrying your own needles and syringes, avoid having injections unless they are absolutely necessary... Avoid tattooing and ear-piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary."

1987-99: Immunization programs deflect HIV worries

In 1974, WHO and partners established the Expanded Programme on Immunization (EPI). For more than a decade, immunizations lagged in Africa. A 1987 meeting of EPI’s Global Advisory Group appreciated that 33% of children in Africa had received their third diphtheria, whooping cough, and tetanus (DPT) vaccination by 1986. The same meeting heard that only 42% of more than 400 immunization centers visited by WHO consultants in 39 African countries sterilized syringes between immunizations.[7] Despite such recognized risks, the meeting recommended: “Continued acceleration” of EPI programs “to meet the goal of Universal Childhood Immunization by 1990.”

In a 1987 joint statement on immunizations, WHO and the United Nations Children’s Fund (UNICEF) imagined a choice between unsafe injections and no immunizations. They opted for unsafe injections: “Halting immunization efforts because of the fear of AIDS would increase deaths among children, while doing little to stop HIV transmission.”[8] That imagined trade-off ignored a third option: safe injections.

In 1989, foreign-funded health experts in Uganda worried that HIV prevention messages warning about risks to get HIV from injections would dissuade mothers from having their children immunized.[9] Based on that concern, a 1989 survey asked mothers if they thought injections could transmit HIV. Mothers aware of the risk were more likely to have had their children immunized. Despite that finding, and even though experts could not “rule out the occasional transmission of HIV via injections... radio messages about AIDS in Uganda have been modified to ensure that parents are aware of the safety of immunizations.”

In 1994, WHO estimated that as many as a third of immunization injections were unsterile in four of WHO’s six regions.[10] In the same year, the head of research at WHO’s Global Programme on AIDS and the future head of UNAIDS worried that outbreak investigations, as in southern Russia in 1988-89, would alert people to bloodborne risks and thereby harm immunization programs:[11] "The media, which has publicized HIV nosocomial outbreaks [i.e., outbreaks from hospitals], has helped to increase public awareness about the dangers of nosocomial transmission. But the short-term benefits of increased public awareness may not always be positive [sic]. The current outbreak of diphtheria in Russia… has been blamed in part on publicity surrounding nosocomial HIV transmission in southern Russia and other problems in the health-care system, which are thought to have discouraged mothers of young children from seeking immunizations from a health-care system that they perceived to be unsafe."

Already in July 1987, WHO staff had been reviewing various designs for syringes and needles that could not be reused, including “auto-destruct” syringes that would break or seize up after use, and pre-filled syringes.[12] But for various reasons, almost nothing happened until the end of the 1990s. As late as 1996, annual sales of auto-destruct syringes had reached only 60 million, equivalent to 6% of the estimated one billion immunization injections given annually in developing countries.[10] For more than a decade, public health officials did not adopt available and simple changes into immunization programs to protect children from unsafe injections.

1999-2003: Breakthrough discussions of HIV from health care

During 1989-98, seven surveys in African countries coordinated by WHO found that 20% to more than 90% of injections were unsafe. At the time, WHO kept most of those findings secret. But the evidence finally broke through. In 1999, the Bulletin of the World Health Organization published survey findings (but without naming many of the countries) along with another paper that used those findings to estimate unsafe injections caused 51,000-102,000 HIV infections in Africa in an unspecified recent year.[13,14]

In response to such worrisome information and estimates, WHO, UNICEF, and the United Nations Population Fund (UNFPA) issued a joint statement promoting auto-disable syringes for immunizations. That statement had teeth in the form of time-bound commitments:[15] “UNICEF announces that, as of 1 January 2001, no procurement service contracts for standard disposable syringes will be entered into… WHO, UNICEF and UNFPA urge that, by the end of 2003, all countries should use only auto-disable syringes for immunization.”

However, immunizations accounted for only about 10% of all injections.[13] Most injections were curative; some delivered birth control. Thus, shifting immunizations to auto-disable syringes averted only a small part of the estimated health damage from unsafe injections.

Safe Injection Global Network (SIGN)

In 1999, WHO and CDC established the Safe Injection Global Network (SIGN) with a small staff and office in WHO. SIGN’s agenda was to coordinate efforts to reduce all unsafe medical injections for all purposes.

Whereas donors funding immunization programs had leverage to promote auto-disable syringes for immunization, donors did not have similar leverage for other medical injections. However, the proposed solution was much the same. SIGN with WHO and donors urged governments and private providers to use auto-disable syringes or new disposable syringes and to sterilize any reused syringes and needles. In addition, SIGN and partners promoted programs to educate the general public to ask for fewer injections and to watch providers take new syringes and needles from sealed packages.

To improve injection safety over time, SIGN developed survey forms to collect information on injection practices, published survey findings, and arranged country-level and international meetings to discuss injection risks and remedies. Reviewing available information, SIGN estimated Africans in 2000 received an average of 2.0-2.2 injections per person per year, of which 17%-19% reused syringes and/or needles – more than 200 million injections per year with reused equipment.[16] From this, SIGN estimated unsafe injections caused 52,000-104,000 HIV infections (best estimate: 83,000) in Africa in 2000.[17]

WHO hosts a debate

During 2002-3, several medical journals published letters and articles calling attention to unexplained infections[18] and estimating – from evidence previously reported in medical journals – that unsafe health care and other bloodborne risks accounted for well over half of HIV infections in Africa.[19,20] In response, WHO hosted a closed-door meeting in March 2003 to discuss the evidence. The 20 attendees – WHO and UNAIDS staff and invited experts – discussed the percentages of HIV infections coming from injections and other bloodborne risks, with a focus on Africa. WHO’s report from the meeting says attendees continued to disagree about how much medical injections contribute to Africa’s HIV epidemics, but notes agreement on two points:[21] "First, that better data on the possible role of unsafe injections, and other health care practices, in HIV transmission are needed… Second, that unnecessary injections should not occur and, whether in the formal or informal health sector, such injections should be safe."

US Senate hearings

Soon after US Senator Jeff Sessions heard about WHO’s 2003 meeting on HIV infections from health care, he arranged two hearings in the US Senate to discuss HIV transmission through health care in Africa. With his leadership, the US committed $300 million over 2003-9 to improve the safety of medical injections and blood transfusions in 15 countries (12 in Africa, Guyana, Haiti, and Vietnam). The US allocated this money through programs managed by USAID, CDC, and other agencies.

2004: WHO and UNAIDS reaffirm their double standard for Africa

If there was any question about how well international acceptance of bloodborne risks and HIV transmission during health care in Africa survived discussions during 1999-2003, two publications in 2004 made it crystal clear the double standard survived. WHO and UNAIDS staff continued to accept that Africans were at risk to get HIV from health care, but they did not want UN staff to take the same risks.

In a prominent 2004 article in The Lancet medical journal, WHO and UNAIDS staff led a team of 15 authors assessing risks for Africans to get HIV from unsafe injections. None of the authors had expertise or responsibility for hospital infection control. Authors repeated WHO’s estimate that Africans received more than 200 million injections per year with reused and unsterilized equipment, but assured: “Washing or, possibly, rinsing or soaking of syringes or needles will dilute any blood that might have contaminated the equipment.”[22]

To their credit, the authors mentioned HIV outbreaks from health care in Russia, Romania, and Libya. But instead of acknowledging that those outbreaks came to light because governments investigated unexplained infections, and that African governments had not done so, they simply denied that what had happened there was relevant for Africa: “To believe [the risks demonstrated in those outbreaks] can be generalized to the African setting is… erroneous.” The authors worried that US Senate “hearings to establish whether HIV/AIDS funds should be devoted to programmes that target unsafe injections” might interfere with efforts to reduce sexual transmission of HIV in Africa.

As noted above, in 1991 WHO published a booklet for UN employees, warning them to avoid skin-piercing health care in Africa. UNAIDS’ 2004 revision of the booklet continued such warnings, but assured safe health care for UN staff:[23] "In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe health-care settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.

Why did the double standard survive?

During 1999-2003, experts in international meetings and medical journals bandied about estimates of more-or-less 100,000 Africans infected each year from medical injections. In many experts’ home countries, such estimates would have brought outrage and immediate investigations to find and treat people who had been infected and to find and fix whatever had infected them. Experts talking about 100,000 infections per year from injections in Africa expected and ignited no such response.

Estimates of infections from injections in Africa were based, in part, on evidence-based estimates that 17%-50% of injections were unsafe.[14,17] In many experts’ home countries, even if an unsafe injection does not infect anyone, it is considered a “near-miss,” “close-call” or “potential adverse event” that should be investigated to find out why it happened and to prevent future mistakes.[24] A similar response was not considered for recognized unsafe injections in Africa.

In other words, much of the 1999-2003 discussion of HIV infections from health care in Africa was carried on within the framework of the double standard. Safe enough for you, but not for us.

Great progress with injections, but missing the big picture

Building on more than a decade of back-room debates about risks with immunizations injections, international health officials and experts who were most concerned about HIV from health care focused on injections. Long-term concerns about HIV and other bloodborne infections from unsafe medical injections broke through to public discussion and attention in 1999.

Attention brought change. The estimated annual number of unsafe injections per person in sub-Saharan Africa fell more than 90% from 2000 to 2011-15.[25,26] Some of this reduction was due to fewer injections, but most was due to less reuse. Although data for 2011-15 are weak (based on patients’ recall for injections received months earlier), there has no doubt been a big drop in numbers of unsafe injections as well as in numbers of HIV (and hepatitis B and C) infections from injections.

But despite fewer unsafe injections, numbers of unexplained HIV infections have remained high (Chapters 4-6). Clearly, the focus on injections has missed the big picture. The decision to ignore medical procedures other than injections and transfusions was reached with insufficient evidence and almost no discussion. The variety and numbers of skin-piercing medical procedures that Africans receive have increased over the years. There is not even good information on what and how many procedures an average person receives in a year, much less on how often instruments are reused without sterilization. The best and quickest way to find such risks is to investigate unexplained infections – to trace infections to facilities and procedures. Outbreak investigations might also find risks with cosmetic procedures, such as tattooing, piercing, and manicures.

Getting providers to shift to auto-disable syringes was a supply-side, technical solution working through healthcare professionals. Some programs advised the public to watch providers take new syringes and needles from sealed packages and to take fewer injections. However, the emphasis was on supply-side interventions, leaving in place weak accountability to patients, which has been the core of the problem.

Even for injections, interventions were insufficient. For example, a parent taking a child for an injection might see the nurse take a new syringe and needle from a sealed package, but if the nurse then takes medicine to inject from an already opened multi-dose vial (with medicine for multiple injections), whatever is injected may have been contaminated by a previous syringe or needle withdrawing medicine from the vial. The risk that injections might transmit HIV could have been eliminated by shifting to either single-dose vials along with new (auto-disable) syringes or to pre-filled syringes.

Moreover, telling healthcare workers again and again how to give safe injections does not always work. Some people are careless, cutting corners and thinking what they do is safe enough. As of 2011-15, according to estimates reported above, Africans were still getting more than 30 million injections per year with reused syringes and needles.[26]

Critics missed the main point

During 1999-2003, I participated in discussions about HIV from unsafe health care in Africa. I did some short-term work for SIGN, co-authored papers in medical journals, presented at WHO’s March 2003 meeting, and testified in the US Senate.

With hindsight, I am chagrinned we missed the main issue. We spent too much time debating the percentage of HIV infections coming from injections and other medical procedures. That percentage is important, but it is a secondary issue. When someone sees an unexplained HIV infection, the public health response – investigating to find and treat others infected from the same source and to find and fix the source – should be the same whatever the percentage of infections in the country or community coming from bloodborne risks.

Moreover, the failure to investigate unexplained infections was an objective failure. Debates about the percentages of HIV infections in Africa coming from bloodborne risks were a messy distraction that resisted resolution since many experts were willing to rely on weak evidence and jerry-rigged models (see Chapter 6). It was frustrating to tilt against wobbly arguments. But that was a sideshow. If the goal was to stop HIV transmission through health care in Africa, we did not need to win debates about estimated percentages. What we needed to do was to call attention to a simple fact: the failure to investigate unexplained infections.

If some of us involved in 1999-2003 discussions had prioritized investigations of unexplained infections, the immediate outcome might have been the same. Based on what has happened before and since, it seems likely that few of those involved in the discussions would have endorsed investigations. But persistently proposing and emphasizing investigations would have called attention to unexplained infections and challenged discussants to recognize investigations as an option. Such a discussion might have promoted parallel debates in communities and governments across Africa about whether to investigate unexplained infections.

International and foreign organizations are not the ones to manage investigations. That is for communities and governments. But what can such organizations and their associated experts say and do to encourage governments to investigate? And what should donors providing health aid do in countries where health care is a risk to transmit HIV? These issues are still pending.

2004-20: More evidence

Decisions made at the end of the 1980s and reconfirmed in 2004 – to accept undetermined numbers of HIV infections from health care in Africa – have stayed in place since. The double standard continues despite multiple large outbreak investigations in Asia (Chapter 2) and new evidence of healthcare risks and unexplained HIV infections in sub- Saharan Africa.

Not sterilizing reused instruments

After international organizations ramped up attention to unsafe injections in 1999-2003, nine African governments surveyed random samples of health facilities. Among other issues, surveys assessed facilities’ ability to process instruments for reuse (with heat sterilization or high level chemical disinfection). Across the nine countries, 83%-98% of hospitals had equipment to process instruments for reuse (Figure 3.1). However, considering all healthcare facilities, including hospitals, clinics, and others, only 17%-94% had equipment to do so. But just having equipment did not ensure reused instruments were sterile. In some facilities, the worker responsible for operating the equipment was not aware of the correct processing time or temperature, and manuals were not available (Figure 3.1 ignores those deficiencies).

More unexplained HIV infections in Africa

Beginning in 2001, many countries in sub-Saharan Africa managed national surveys to test people for HIV. Surveys found and reported unexplained HIV infections in youth and adults who said they were virgins. Some surveys reported HIV in children with HIV-negative mothers. Because unexplained infections challenge African governments to investigate, I report such data in Chapter 4.

2004-20: More inadequate responses

World Alliance for Patient Safety

Responding to increasing concerns about healthcare providers not washing their hands, giving the wrong drugs, and other mistakes, WHO in 2004 established the World Alliance for Patient Safety. Among its other suggestions, the Alliance recommended reporting and learning from adverse events, such as unexplained infections:[36] "A major element of programmes to improve patient safety is having the capacity and capability to capture comprehensive information on adverse events, errors and near-misses so that it can be used as a source of learning and as the basis for preventive action in the future."

The Alliance urged health facilities and ministries to investigate adverse events to find and fix mistakes.[24] The focus on adverse events was on target – a breath of fresh air!

However, the Alliance has ignored unexplained HIV infections in sub-Saharan Africa as adverse events. During its lifetime, the Alliance has been silent about investigations of large HIV outbreaks in Kazakhstan, Kyrgyzstan, Uzbekistan, Cambodia, and Pakistan. These tragedies are relevant for Africa. Experiences in these countries could provide guidance about how to work with the public during an investigation, how to improve healthcare systems, and how to continue high-priority healthcare programs. Neither the Alliance nor any of the foreign organization helping with recent investigations in Asia has proposed similar investigations in Africa.

Continuing a limited focus on injections

In 2015, WHO recommended countries to shift to “safety-engineered syringes” for most injections, not only immunizations.[37,38] Safety- engineered syringes are auto-disable syringes with additional features to protect healthcare workers from “needlestick accidents” (getting stuck with a used needle). Common designs to prevent needlestick accidents have a flap or sleeve to cover a needle after use. WHO’s 2015 injection safety strategy parallels the strategy SIGN and partners promoted from 1999 for immunization injections: a technical solution that works through health professionals. The strategy ignores skin-piercing procedures other than injections and says nothing about investigating unexplained infections.

HIV prevention programs say little about HIV from health care

WHO’s Global Health Sector Strategy on HIV 2016-21 acknowledges (page 33[39]): “Although reliable data are lacking, it is likely that unsafe medical injections and blood transfusions account for significant numbers of new HIV infections.” The strategy endorses WHO’s 2015 injection safety policy (see previous paragraph). But HIV from health care is clearly not a big issue: the 50-page document commits only one paragraph and several clauses to healthcare risks. UNAIDS was even less attentive. UNAIDS’ strategy for 2016-21 does not mention HIV from unsafe health care, medical injections, or transfusions.[40]

Scientific and medical elites avoid the obvious

Over the years, respected and influential organizations with deep involvement in Africa have been silent about unexplained infections. For example, in 1996, Harvard University with the government of Botswana established the Botswana-Harvard AIDS Institute Partnership, aiming “to develop interventions appropriate to stemming the epidemic.”[41] Botswana has one of the world’s worst HIV epidemics, with an estimated 20.7%-26.1% of adults HIV-positive during 1996-2019. As far as I have been able to see, for more than two decades, no one associated with Harvard’s work in Botswana has asked about or said anything about bloodborne risks or unexplained HIV infections.

Partners in Health, a US-based non-government organization, has made major contributions to HIV treatment for Africans (see Chapter 7). At the request of the government of Lesotho, Partners in Health began working in Lesotho in 2006. According to UNAIDS estimates, 22.8%-24.6% of adults in Lesotho have been HIV-positive from 2006 through 2019.[42] During 14 years, Partners in Health staff have no doubt met and heard of many people with unexplained infections. But as far as I can see, no one associated with Partners in Health has mentioned such infections or asked for any investigation to find their source.

Much of what Harvard University and Partners in Health have done in Botswana and Lesotho is great, for example, helping to extend antiretroviral treatment. But by staying silent about unexplained infections and not urging investigations (at least not publicly), they have not protected people.

Why such bad advice?

Accepting that health care transmits HIV to an unknown number of people without asking for investigations or warning people at risk is inconsistent with health professionals’ responsibilities as described in the World Medical Association’s Declaration of Lisbon on the Rights of the Patient: “Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights,” including (article 1) “The right to medical care of good quality” and (article 9) “the right to health education that will assist him/her in making informed choices about personal health and about the available health services.”[43] Not warning people about risks is similarly inconsistent with the Preamble to the Constitution of the World Health Organization: “Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.”[44]

Excuse for abuse

The priority for foreign health aid in sub-Saharan Africa has been to extend interventions – more children immunized, more pregnant women attending antenatal care, more hospital deliveries, more primary health care. A common excuse for discouraging outbreak investigations and for not telling people about risks to get HIV from medical procedures has been that warning people might scare them away from health care. This excuse:

• • Does not respect the public’s role in making health care safe. Not telling the public about risks in health care does not give them the information they need to help reduce those risks.

  • Does not allow people to make their own choices. People should be informed and thereby allowed to decide for themselves if they would rather risk getting HIV from a specific healthcare procedure or risk the consequences from forgoing it.

  • Assumes healthcare managers and patients have two choices: unsafe health care or no health care. This overlooks safe care as a third option.

For healthcare professionals, the excuse that warning people about risks might scare them away from health care is self-serving. Not warning protects medical professionals from accountability to patients, which might be uncomfortable. Other reasons for silence may be to protect their jobs or institutions by not saying something employers, funders, or supervisors might not want to hear.

Racial stereotypes and the white-savior complex

Most experts knowledgeable about HIV in Africa have by now accepted survey-based evidence that sexual behavior in Africa is not horrendously promiscuous. But among the European and American public, across the political spectrum from left to right, racial stereotypes of sexual behavior are still widespread. With such beliefs, the European and American public accepts that sex explains Africa’s HIV epidemics. Such blindness among the public in donor countries protects the bad advice that international and foreign organizations have been giving Africans: ignore unexplained infections, accept unknown numbers of infections from health care, and focus on sexual risks.

Another problematic belief among Europeans and Americans is the white savior complex – that foreign aid can solve Africa’s problems. Finding and stopping HIV transmission through health care does not need foreign aid. The solution requires healthcare managers and providers to be accountable to patients. Foreign aid can undermine that solution by strengthening accountability to paymasters, which can weaken accountability to patients.

Dissent

Not all health experts outside sub-Saharan Africa have gone along with the double standard. For example, 15 authors of two papers, in 2003[45] and 2009,[46] asked for outbreak investigations in Africa. Authors include the head of the International Clinical Epidemiology Network, editor of a medical journal, a staff of Physicians for Human Rights, professors at universities in India, Germany, and Ireland, members of other organizations, and independent experts.

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