[this is the 3rd of 3 parts; click here to get the complete paper]
6. Wherever governments investigate unexpected HIV infections, HIV concentrates in MSMs and IDUs
An unexpected infection – for example, in a child with an HIV-negative mother or a woman with one lifetime HIV-negative sex partner – is a warning that people may be getting infections from an unknown source. Many governments outside Africa have reacted to unexpected infections by investigations – tracing and testing patients who attended specific hospitals or clinics suspected to be the source of the unexpected HIV infection (Table). Such investigations are able to stop further damage by finding others who are infected and thereby identifying the procedures and errors that led to infections. No country in which the government investigated unexpected HIV infections has a generalized epidemic.
Table: Investigated HIV outbreaks from unsafe health care procedures (outbreaks with 100 or more infections)
|Country, year of outbreak
||Who was infected
||Number of cases
|Mexico, circa 1986
||Blood and plasma sellers
|Russia, Elista, 1988-89
|India, Mumbai, 1988
||Blood and plasma sellers
||Blood and plasma sellers
||Inpatient and outpatient children
For example, in 1989, doctors in a Romanian hospital found several children with HIV but with HIV-negative mothers. In response, doctors and later the government tested thousands of children in 1989-91, found more than 1,000 with HIV, and determined that most infections came from injections. Investigations alerted the public and providers to demand and ensure safe care. Currently, less than 0.1% (1 in 1,000) of Romanians are infected – one of the lowest levels in the world.
In contrast, even though unexpected infections are common in sub-Saharan Africa, no African government has investigated any unexpected HIV infection by tracing and testing other patients who attended a suspected clinic or hospital. The failure to investigate is like smelling smoke, but then going back to sleep and letting the house burn down. Here are some unexpected infections that African governments could have and should have investigated, but didn’t:
- In 1985, researchers tested inpatient and outpatient children aged 0-2 years in Kinshasa, DRC. Out of 44 children found with HIV, 17 (39%) had mothers who were HIV-negative. “[M]edical injections seemed to be the most important risk factor for HIV seropositivity, followed by…blood transfusions or hospital admission.” The study team noted “Injections are often administered in dispensaries which reuse needles and syringes yet may not adequately sterilize them.”
- In 1984-86, researchers in Kigali, Rwanda, tested mothers of 76 children aged 0-4 years with AIDS. Eighteen (24%) of 76 mothers were HIV-negative.
- In 1991-93, WHO coordinated research in 4 cities in Africa (Dar es Salaam, Kampala, Kigali, and Lusaka) to test inpatient children aged 6 months to 5 years and their mothers for HIV. Sixty-one (1.1%) of 5,593 children were HIV-positive with HIV-negative mothers. WHO concluded “the risk of…patient-to-patient transmission of HIV among children in health care settings is low.”
- Recent national surveys in Uganda (two surveys, in 2004-05 and 2011), Swaziland (2006-07), and Mozambique (2009) found 16%-31% of HIV-positive children to have HIV-negative mothers (among children with tested mothers).
Unexplained infections are also common in adults with no sexual risks, including virgin men and women. For example:
7. Wherever governments react to stop unsafe health care, HIV concentrates in MSM and IDUs
In the US and Europe, governments arrange several mechanisms to find and stop reuse of unsterilized skin-piercing instruments in health care. These mechanisms include regulations describing acceptable practices, licenses, inspections, and courts that allow patients to sue for damages. When someone reports unsafe procedures in a health facility, inspectors visit the facility. If the error is considered dangerous to pass infections among patients, governments may trace and test patients.
In the US and Europe, it’s not only governments that are vigilant about risks to get HIV from blood, so is the general public. For example, if a participant in a sporting contest gets a bleeding cut, referees send him or her to the sidelines. The player is not allowed to return to the game until his or her cut has been covered.
In contrast to what happens in the US and Europe, unsafe procedures are common and tolerated in Africa. As already reported at the beginning of this note, many health care facilities lack equipment to sterilize instruments, and many people accept cosmetic services in public places with unsterilized instruments that could pierce their skin.
Break the silence
Health care professionals from Geneva to African ministries of health to hospitals and clinics in towns and cities across Africa have largely ignored HIV transmission through health care. As far as I can see, their silence comes at least in part from not wanting or not knowing how to tell the public there is a problem. Because health care professionals have not wanted to talk about the problem, it’s up to the public at risk to break the silence. Here are some suggestions about what people can do to break the silence and thereby to protect themselves and others.
Avoid contaminated instruments: People who are aware of blood-borne risks can avoid contaminated skin-piercing instruments. A general strategy to do so boils down to four options: avoid the procedure, use disposable instruments, patients/clients sterilize instruments, or talk with providers to ensure they sterilize instruments. Further suggestions about this strategy are available at: http://dontgetstuck.wordpress.com, with pages on injections, tattooing, etc.
Talk about unexpected infections: Individual efforts to avoid unsterilized instruments do not always work. People may not feel comfortable asking a doctor or nurse if instruments have been sterilized. Moreover, in a lot of situations – such as in an emergency – people have little or no chance to control the instruments used on them. In other words, to be really safe from blood-borne HIV people need to ensure that hospitals and clinics in their communities are not making careless errors.
Investigations are the key to finding and stopping errors. People who are aware of risk can help to lay the groundwork for investigations by talking with others in their communities about risks to get HIV from skin-piercing procedures. Then, whenever an unexpected infection gets recognized in the community, more people will be aware of their own risk, and could work together to push for investigations through political leaders, the media, and courts.
The objective of an investigation should not be to punish anyone or to collect damages for victims but rather to find others who have been infected and thereby to find and stop errors. Many African governments already offer free treatment for HIV, so victims can get care. During investigations, health staff should be assured they will not be blamed or punished for errors.
HIV prevention programs aimed exclusively at sexual transmission have failed to stop HIV in Africa – they do not protect people from all risks. People at risk can do something different to get different results: beware unsterile skin-piercing instruments, and break the silence to urge their communities and governments to address blood-borne and not only sexual risks.
 Avila C, et al; AIDS 1989; 3: 631-3.
 Bobkov A, et al; AIDS 1994; 8: 619-624. Pokrovskii VV, et al. Zh Microbiol Epidemiol Immunobiol 1990, 4: 17-23. Pokrovsky VV; 8th Int Conf AIDS, Amsterdam 19-24 July 1992; abstract PoC 4138. Sauhat SR, et al; 8th Int Conf AIDS, Amsterdam 19-24 July 1992, abstract PoC 4288.
 Patrascu IV, Dumitrescu O; AIDS Res Hum Retroviruses 1993; 9: 99-104. Apetrei C, et al. AIDS Res Hum Retroviruses 1997; 13: 363-5. Drucker E, et al; In Sande MA, et al; Global HIV/AIDS Medicine; Philadelphia: Saunders, 2007.
 Bhimani GV, Gilada IS; 8th Int Conf AIDS, Amsterdam 19-24 July 1992; abstract MoC00937.
 Wu Z, et al; Health Policy Plan 2001; 16: 41-6. Wu Z, et al; Lancet 1995; 346: 61-2. UNAIDS, 2005 Update on the HIV/AIDS epidemic and response in China; WHO, 2006.
 Visco-Comandini U, et al. AIDS Res Hum Retroviruses 2002; 18: 727-32. de Oliviera T, et al; Nature 2006; 444: 836-7.
 Thome C, et al; Lancet Infect Dis 2010; 10: 479-488.
 Mann JM, Francis H, Davachi F, et al. ‘Risk factors for human immunodeficiency virus seropositivity among children 1-24 months old in Kinshasa, Zaire’, Lancet, 1986, ii: 654-7.
 Lepage P, Van de Perre P, Carael M, et al. ‘Are medical injections a risk factor for HIV in children?’, Lancet, 1986, ii: 1103-4.
 Lepage P, Van de Perre P. Nosocomial transmission of HIV in Africa: What tribute is paid to contaminated blood transfusions and medical injections? Infect Control Hosp Epidemiol 1988, 9: 200-3.
 Hitimana D, Luo-Mutti C, Madraa B, et al. ‘A multicentre matched case control study of possible nosocomial HIV-1 transmission in infants and children in developing countries’, 9th Int Conf AIDS, Berlin 6-11 June 1993. Abstract no. WS-C13-2. Available at: http://www.aegis.com/aidsline/1993/nov/M93B3075.html (accessed 9 September 2007).
Global Programme on AIDS. 1992-1993 Progress Report, Global Programme on AIDS. Geneva: WHO, 1993. p. 85.
 See pp. 177-181 in: Instituto Nacional de Saúde (INS), Instituto Nacional de Estatística (INE), e ICF Macro. 2010. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique 2009. Calverton, Maryland, EUA: INS, INE e ICF Macro. Available at: http://measuredhs.com/publications/publication-AIS8-AIS-Final-Reports.cfm (accessed 17 October 2012).
 See Table 7.5 in: Centre National de la Statistique et des Études Économiques (CNSEE). Enquête de Séroprévalence et sur les Indicateurs du Sida du Congo (ESISC-I) 2009. Brazzaville: CNSEE, 2009. Available at: http://www.measuredhs.com/pubs/pdf/AIS7/AIS7.pdf (accessed 8 July 2011).