AVERT - AVERTing HIV and AIDS

One of the primary routes of HIV transmission is through direct contact between your blood and HIV infected blood. Although the majority of HIV infections via blood occur through injecting drug use, medical settings still account for a significant number of new HIV infections. Across the world numerous cases of HIV transmission through blood transfusions, medical injections, medical waste and occupational exposure, are both reported and unreported. 

There are an estimated 250,000 new infections per year as a result of the reuse of needles and syringes1, and in Africa 250 to 500 people are newly infected with HIV each day as a result of unsafe blood transfusions.2 3 Testing of blood is essential but remains absent in many low and middle-income countries.

Blood: Donations, transfusions and HIV

Blood transfusions are essential treatment for excessive blood loss and for diseases such as haemophilia. If a person receives a blood transfusion with HIV-infected blood, there is a 95 percent risk they will become infected with the virus.4 However the chances of becoming infected with HIV through a blood transfusion varies between countries depending on the level of safety precautions in place, and there is a notable difference between developed and developing countries. In the UK, the risk is now 1 in 5 million. 5

The first tests for HIV in donor blood were not implemented in countries until 1985, four years after the first case of AIDS was reported. Between 1985 and 1992, the United States, France and Romania had the highest number of AIDS diagnosis as a result of HIV infection through transfusion, with more than 8,000 people in the US believed to have acquired HIV through transfusion during this period.6

“HIV infection continues to be a risk associated with blood transfusions ”

Haemophilia is a disease characterized by the deficiency of blood clotting factors in the blood. 7 This condition is treated through the frequent transfusion of blood products such as plasma, which contain platelets, and clotting factors, such as factor VIII.8 9 Thousands of haemophiliacs contracted HIV through receiving these life saving blood products during the late 1970s and 1980s a time when blood was pooled to extract the factor VIII and not screened or treated for HIV.10 11 Plasma is a blood product which can be heat treated and since heat treatment was implemented in 1985, plasma is now completely safe where this method is used.12

The World Health Organisation (WHO) outlines a number of recommendations which countries should follow to maintain a safe and constant blood supply. These steps prevent transfusion-transmissible infections (TTI), which include HIV-1, HIV-2, hepatitis B, hepatitis C and syphilis, passing from a blood donor to the recipient of a blood transfusion.13 According to the recommendations countries need:

  • A nationally coordinated blood transfusion service
  • Voluntary unpaid donors
  • To test all donated blood
  • To use blood efficiently and appropriately
  • To ensure a safe transfusion practice
  • To have a quality systems check throughout the blood transfusion process.

The roll-out of widespread safety measures such as donor selection and screening guidelines makes the risk of HIV transmission today virtually non-existent in developed countries.14 However, where guidelines for blood safety have not been implemented or are not followed, HIV infection continues to be a risk associated with blood transfusions.

HIV and blood donors: Who can donate?

A key aspect of ensuring a safe blood supply is the screening and counselling of donors to limit the number of people infected with HIV from donating.

Voluntary, non-remunerated blood donors are those who donate on their own accord without coercion or incentives, such as money. In some countries, such as the UK, 100 percent of donations come from voluntary, non-remunerated donors. The recommendation by WHO to only use this type of donor was first made in 1975 in the form of the World Health Assembly resolution 28.72.15 These donors are sought after because they are more likely to be donating for altruistic reasons rather than for any personal gain.16 Injecting drug users are more at risk of HIV infection and often need money to fund their drug habit. If donating blood is seen as a source of income, individuals such as IDUs are more likely to donate and therefore risk the safety of blood supplies.

When an individual needs a donation and a family member steps forward to donate blood they are referred to as a ‘family/replacement’ donor. However, like paid donors, this type of donor often leads to higher number of HIV-infected blood donations. In many countries paid donors and family blood donors continue to make up a large percent of blood donations. For example, 70 percent of donations in Pakistan are from ‘family and replacement’ donors with a further 10 percent of donations from paid donors.17 The risk posed by these donors is illustrated by 2008 figures which show that 6.8 percent of IDUs in Pakistan admit to selling blood in return for money and in some provinces HIV prevalence in blood donations is more than 5 percent.18

The process of screening donors involves asking a series of questions about the donors’ lifestyle to ensure individuals who participate in risky behavior, such as IDUs, or those who fall into a group which has a high-HIV prevalence, such as men who have sex with men, do not donate blood.19 20

The debate: Men who have sex with men (MSM) donating blood

The ban on MSM from donating blood is currently enforced in many countries, such as the UK and the United States. The United States’ ban was enacted in 1983 before testing of donor blood for HIV began, as more MSM were infected with HIV than other donor groups.

The United States policy bans any man who has had sex with a man since 1977 (which includes single encounters) from donating for life. However, the policy for heterosexuals is markedly different. For example, a heterosexual is deferred for only 12 months if they have sex with a man who has sex with men (if you are female), an injecting drug user, or a sex worker.21

“the ban is outdated and unscientific”

Banning MSM from giving blood has been a controversial issue for some time. Many argue that the ban is outdated and unscientific as many MSM are in long term relationships and practice safe sex but are banned for life, whereas heterosexuals who engage in risky behaviour are only banned for a year.22 23 24 25 26 Organisations such as the American Red Cross support a deferral rather than a lifetime ban for MSM.27 It is believed that a donor should be evaluated on the risk they pose by the behaviour they engage in, rather than the group they fall into.28 On these grounds it is argued that eligibility questions should be reviewed. The availability of nucleic acid tests (NAT), which reduces the window period and makes testing much more accurate, helped to support the argument for a change in the ban against MSM donating. These tests have been found to almost eliminate the possibility that HIV infected blood will pass through the testing stage, even in countries with high prevalence.29

In support of upholding the current policy, the Centre for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) identify that in the US, HIV prevalence in those MSM who are likely to donate is 15 times higher than the general population.30 31 FDA modelling illustrates the increase in risk by introducing a deferral period for MSM, like those used for individuals such as sex workers. A 12 month deferral will result in 1,600 more HIV infected units being donated, detection of which will rely on screening.32

Following a review in June 2010 the Advisory committee on Blood Safety and Availability decided to uphold the ban against MSM donating. They claimed that further scientific research was needed on this topic.33

How is blood tested for HIV?

Testing ‘algorithms’ are a sequence of specific tests, or assays, which are organised to create a certain HIV testing strategy.34 These must take into consideration the resources, infrastructure and staff expertise available in different countries so the specified algorithms are always followed, to ensure consistency in the testing of blood.35

Screening blood for HIV in Kazakhstan

Screening blood for HIV in Kazakhstan

Initial HIV testing uses antibody tests to detect antibodies to HIV in the blood. As the virus becomes established the body makes increasing amounts of antibodies. However, it can take between 3 weeks and 3 months after initial infection before an individual produces antibodies and HIV is detectable. This gap is known as the window period and blood donations infected with HIV screened with antibody tests at this time may not be detected.36

However, other tests exist to further reduce this window period, such as p24 antigen tests, which screen for proteins attached to the HIV infected cell and nucleic acid testing (NAT), which screen for the genetic material of HIV.37 These tests reduce the window period down to about 12 days. It is because these 12 days remain that donor screening and counselling is still important to further reduce the chance of a person infected with HIV giving blood.

The NAT test is particularly important where prevalence is high as the number of window period donations are more likely. However, HIV prevalence is often highest in poorer countries and unfortunately NAT tests are expensive and therefore these countries usually only have antibody tests. The chance that an HIV-infected donation will not be detected is therefore greater in these countries.

In 2009 blood screened for HIV in Greater Accra, Ghana amounted to 33,294 units of blood, of which 3.68 percent was found to be HIV positive. 38 Ghana tests 100 percent of its blood donations, however this is done using only antibody tests. Therefore the window period remains a significant interval, which suggests some units may continue to pass through screening undetected.

In October 2005, South Africa introduced NAT testing and as a result there were no cases of HIV transmission by blood transfusion reported to the haemovigilance programme, a transfusion surveillance system.39 40

During the testing process a screening policy, good laboratory practice and a quality assurance system should be in place to avoid any HIV positive samples passing undetected. 41 42 The WHO asserts this is reliant on the formulation and implementation of a national blood policy by a country’s government.43

Do all countries test for HIV?

More than 85 million blood donations took place in 2007 across 162 countries, of which 41 lacked the resources to screen for transfusion-transmissible infections (TTIs).44 UNAIDS figures show only half of Pakistan’s annual 1.5 million bags of transfused blood are screened45 and it is believed that 19 percent of new HIV infections in Pakistan are due to unsafe blood.46 47
Worryingly it is often countries with a high HIV prevalence that have inadequate screening programmes in place. In Tanzania, HIV prevalence is 5.7 percent and yet blood screening is extremely limited.48 For example, 2007 data shows only 125,000 of the 350,000 units of blood donated or 35.7 percent were screened for HIV and other TTIs.49

The situation in China during the early years of the epidemic highlights the need not only for voluntary, non-remunerated donors but also safe procedures for blood collection, testing and transfusion.50 Farmers from Henan province donated blood during the 1990s to collection sites where, to save money, the donors blood was pooled, the plasma extracted and then the remaining blood injected back into the donor.51 52 More than 100,000 farmers were infected with HIV in this way and unknowingly continued to donate infected blood, which was passed on through blood transfusion.

The importance of safe, sustainable blood supplies

Blood shortages can increase the risk of HIV transmission through blood transfusion as health authorities may become less stringent about the source of donated blood.53 54 This is especially problematic when screening is not in place and when HIV prevalence is high.

Acquiring 100% voluntary, non-remunerated donors is a challenge for many countries. For a country to maintain a sustainable blood supply only 1 to 3 percent of a country’s population need to donate blood. However, 2007 figures show the donation rate in 73 countries, out of 162 surveyed, is less than 1 percent of the population.55

Blood donation rates are considerably less in developing countries when compared to transitional countries, which have a donation rate 3 times higher, and developed countries, which have a donation rate 11 times higher.56 For example, sub-Saharan Africa is home to 14 percent of the world’s population, yet total blood donations are estimated to be 6.3 percent of the total global blood donations.57 58

Sometimes cultural factors may inhibit the success of blood programmes. For example in China, cultural beliefs are often the cause of blood shortages. In traditional Chinese culture the loss of blood is not only detrimental to your health but also a disloyal act against your ancestors.59 However, on the other hand it is also believed that receiving an unnecessary blood transfusion benefits your health and in many rural parts this practice is used as a ‘health booster’.60 61 Inappropriate clinical use of blood, such as this, not only contributes to blood shortages, but in countries which do not test blood appropriately, can increase the risk of HIV infection.

Those most in need of safe blood and therefore most vulnerable from blood shortages and unscreened blood are pregnant women, children and haemophiliacs.62 63 A lack of safe blood in southern Africa accounts for an estimated 15 percent of anemia related child deaths64 65 and 44 percent of maternal deaths are due to hemorrhaging during pregnancy in sub-Saharan Africa.66 67

Attempts globally to meet the Millennium Development Goals 4 (to reduce child mortality), 5 (Improve maternal health) and 6 (to combat HIV/AIDS, malaria and other diseases)68 will not be achieved without persistent efforts by individual countries to develop safe and sustainable blood supplies.

Medical injections and HIV

The Safe Injection Global Network defines a safe injection to be:

“Safe for the patient, the health worker and the environment”69

Medical injections are injections received as treatment, or for the prevention of ill-health (for example immunisation).

Once a person receives an injection a small amount of their blood can remain on the needle or syringe. If the person was infected with HIV and the same needle or syringe is used on another person, without correct sterilization there is a risk they may become infected with HIV. HIV infected blood on needles, syringes and other medical equipment can survive for up to two hours outside of the body70 and it has been found that syringes containing HIV infected blood can still transmit HIV, even after being rinsed, for up to 4 weeks.71 Studies have illustrated the parallel between the re-use of equipment and infection with blood borne viruses.72 73

The reuse of unsterilized needles and syringes can be prevented by using AD syringes.

The reuse of unsterilized needles and syringes can be prevented by using AD syringes.

Receiving injections in healthcare settings is very safe in developed countries. Health workers in these countries have easy access to new equipment and have undertaken training in safe practice. However, access to training, new equipment and resources to sterilize equipment is often lacking in developing countries and generally it is in these countries where the transmission of HIV infection, in healthcare settings, occurs.74 Gross re-use of medical equipment, including syringes, was reported in three of Kazakhstan’s Hospitals in 2007.75 Furthermore, in Romania, more than 10,000 new babies and young children were infected with HIV from contaminated injections and unscreened blood transfusions between 1987 and 1991.76

Health systems must be strengthened to provide healthcare workers with training and resources if injections are to be made safer.77 78 Similarly, patients must be made aware that medical equipment should be new or sterilised before use.

Only estimates of the probability of becoming infected with HIV through an unsafe medical injection are available and whereas WHO estimates it to be 1.2 percent, other estimates vary from 0.1 percent and 6.9 percent.79 Some have identified medical injections in sub-Saharan Africa as a major cause of new HIV infections and claim 20-40% of infections are from medical injections.80 81 82 83 84 85 However, WHO estimates for sub-Saharan Africa are far more conservative at 2.5 percent.86 87 They uphold that although HIV transmission in healthcare settings, notably medical injections, is an area of concern, most infections are sexually transmitted.88

Controversy aside it is evident that unsafe procedures when administering medical injections have serious repercussions for the spread of HIV and despite the risks, un-sterilized needles and syringes continue to be re-used. As WHO figures show, across the world up to 39 percent of injections are administered with equipment that has previously been used and un-sterilized.89

The Safe Injection Global Network (SIGN)90 and the Presidents Emergency Plan For AIDS Relief (PEPFAR) are examples of governments and organisations working to promote safe injection and healthcare practices to eliminate the risks to patients and healthcare workers.91 ‘Making Medical Injections Safer’ (MMIS)92, funded by PEPFAR, works in 11 countries alongside host governments to promote the safe use and disposal of unsafe injections through initiatives such as the training and education of healthcare providers.93 For example an MMIS project in Tanzania during December 2006 resulted in the training of more than 8,000 healthcare workers in safe injection practices.94

Technology such as single dose, pre-filled Auto-Disable (AD) injection devices (used for vaccinations) and AD syringes95, which have a one-way valve making the syringe useless after one use, have the potential to make injections in developing countries safer.96 97 98 Currently, AD syringes are used mainly for immunisation programmes where the potential for the reuse of injection equipment is high. A 2003 joint statement from WHO, UNICEF and UNFPA stated that AD syringes should be used for immunisations, particularly during immunising campaigns.99 However, vaccinations only account for 10 percent of injections whereas 90 percent are for curative (or treatment) purposes.100

The Indian government issued a mandate in 2008 for the use of AD syringes in all government health facilities, for both curative and immunising purposes.101 Despite the phasing out of sterilizable and disposable syringes by some international organizations and governments, both continue to be used instead of AD syringes.102 The most recent study found the percentage of non-industrialised countries using AD syringes for routine immunisation had increased since the previous study to 62 percent. However, exclusive use of AD syringes was still low at 38 percent.103 Sterilizable syringes rely on the safe practice of the user, which can fluctuate in response to other factors. For example, sterilization may be overlooked during busy periods, such as mass vaccination campaigns, or when access to resources is limited, such as fuel to boil water.

Medical waste is routinely collected for resale.

Medical waste is routinely collected for resale.

Unsafe practices such as only rinsing needles between vaccinations have been recorded. For example in Gudamb, India, a rural health worker who carried out such a procedure stated, “for sterilization we are supposed to carry kerosene and a cooking stove with us…but for six months there has been no kerosene supply… for me, immunizing the children is a bigger priority”.104 Disposable syringes can also be reused and generate large amounts of waste, which often fuels the demand for cheap injection equipment and can be associated with the transmission of HIV.

However, AD syringes are safe irrespective of the environment they are being used in and only cost 2 cents more than traditional syringes (since they were first introduced, the cost of AD syringes has declined from US15 cents to US6 cents).105 106 UNICEF mass vaccination campaigns can vaccinate an estimated 10 million children in one week and they use only AD syringes.107

Waste disposal is a problem if correct facilities are not in place (incinerators) – but AD syringes cannot be collected and sold for reuse. Access to AD devices in remote areas may be problematic. However, if governments accept the need for injection safety and AD syringes become readily available, it is likely that the disposal of and access to AD syringes will cease to be a problem – as will HIV transmission through injections.

Whereas the reuse of medical equipment occurs predominantly in developing countries, healthcare facilities in developed countries are still not 100 percent risk averse, despite the overall high level of conformity to safety guidelines. In 2008, a health clinic in Las Vegas in the United States was closed following evidence that syringes were being reused and equipment used for colonoscopies was not being cleaned between patients. 108 109 This resulted in 40,000 people requiring tests for HIV, hepatitis C and B.110 The CDC campaign slogan “One Needle, One Syringe, Only One Time” is aimed at health workers in America to raise awareness of the importance of new equipment.111

Is an injection the only answer?

In some countries the risk of HIV infection through medical injection can be limited by keeping the number of injections received to a minimum. Studies in sub-Saharan Africa indicate that individuals who receive 5 or more medical injections are 2.3 times more at risk of being infected with HIV than those who do not.112 In Uganda, a correlation between HIV prevalence and having more than 5 medical injections was found. Of those who received 5 or more injections 10.8 percent of men and 11.4 percent of women were infected with HIV, whereas 4.0 percent of men and 6.3 percent of women, of those who had not received an injection, were infected with HIV.113

WHO estimates that up to 70 percent of injections in some countries, were ‘medically unnecessary’.114 115 For example, in some countries injections are given unnecessarily to administer antibiotics or vitamins.116 117 Oral medication is an alternative to injections and this treatment should be used wherever possible. To reinforce efforts to minimize the use of injections and therefore reduce the HIV risk in healthcare settings, patients in low and middle-income countries, where injection safety is often low and HIV prevalence high, need to question whether they really need the injections.

Occupational exposure and HIV

If precautions are not followed healthcare workers may be at risk of HIV infection as a result of their work. The main cause of infection in occupational settings is exposure to HIV-infected blood via a percutaneous injury (i.e. from needles, instruments, bites which break the skin, etc.). The average risk for HIV transmission after such exposure to infected blood is low - about 3 per 1,000 injuries. Nevertheless, this is still understandably an area of considerable concern for many health care workers.118

Certain specific factors may mean a percutaneous injury carries a higher risk, for example:

  • A deep injury
  • A high viral load in the patient (which means they will be more infectious)
  • Visible blood on the device that caused the injury
  • Injury with a needle that had been placed in a source patient's artery or vein

If percutaneous exposure occurs then the site of exposure should be washed liberally with soap and water but without scrubbing. Bleeding should be encouraged by pressing gently around the site of the injury (but taking care not to press immediately on the injury site). It is best to do this under a running water tap.

“If intact skin is exposed to HIV infected blood then there is no risk of HIV transmission”

There are a small number of instances where HIV has been acquired through contact with non-intact skin or mucous membranes (i.e. splashes of infected blood in the eye). Research suggests that the risk of HIV infection after mucous membrane exposure is less than 1 in 1000.119 If mucocutaneous exposure occurs then the affected area should be washed thoroughly with soap and water. If the eye is affected, it should be irrigated thoroughly.

If intact skin is exposed to HIV infected blood then there is no risk of HIV transmission.120

How many occupational infections have been reported?

Up until December 2006, health care workers in the USA reported 57 occupational HIV infections. Of these, 48 had percutaneous exposure; 5, mucocutaneous exposure; 2, both percutaneous and mucocutaneous exposure; and 2, an unknown route of exposure. In addition, 140 possible occupational transmissions have occurred among healthcare personnel. These are cases in which a worker is infected with HIV and has a history of occupational exposure, but did not have a test immediately before and after the possible exposure. As no other risk factors are reported, it is most likely that the infection has occurred as a result of that occupational exposure.121

It should be noted that because of the voluntary nature of the reporting system, there might be some under-reporting of cases. In addition, the U.S. Centers for Disease Control and Prevention emphasise that over 90 percent of health care workers infected with HIV also have non-occupational risk factors for acquiring their infection. 122

In the UK, as of November 2008, the Health Protection Agency (HPA) has reported that there have been five documented cases of HIV infection after occupational exposure in the healthcare setting, the last being in 1999. 123

What are Universal Precautions?

Universal precautions protect healthcare workers, patients and the environment.

In a healthcare setting workers should take precautions with everybody to eliminate the need to make assumptions about people’s lifestyles and how much of a risk they present. Health care workers should have the right to be able to protect themselves against infection, whether it is HIV, Hepatitis or other TTIs.

The following universal infection control precautions are advised by the World Health Organization124 to help protect health care workers from blood-borne infections including HIV:

  • Hand washing after direct contact with patients.
  • Use of protective barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood and other body fluids.
  • Safe collection and disposal of needles and sharps, with required puncture- and liquid- proof boxes in each patient care area.
  • Preventing two-handed recapping of needles.
  • Covering all cuts and abrasions with a waterproof dressing.
  • Promptly and carefully cleaning up spills of blood and other body fluids.
  • Using a safe system for health care waste management and disposal.

Appropriate waste disposal is essential to prevent used and potentially contaminated medical equipment being recycled. However, this is reliant on the necessary disposal facilities being in place. 125 The use of sharps boxes for used needles prevents health workers from injuring themselves or re-using them. It also protects members of the public from exposure to needles, which can easily occur if medical waste is disposed of alongside normal refuse.

Post-exposure Prophylaxis

Research has shown that the use of antiretroviral drugs if given soon after an injury may reduce the risk of transmission. Such treatment is referred to as Post-exposure Prophylaxis (PEP). PEP is recommended for health care workers if they have had a significant occupational exposure to blood or another high-risk body fluid that is likely to be infected with HIV.126

Although exposure through needlestick injuries can usually be avoided by following good working practices, health care workers should consider the implications of taking PEP. This will help them to make a swift decision in the event of an accident where an injury occurs.

Medical waste and HIV

Recycling of medical waste risks HIV transmission

Recycling of medical waste risks HIV transmission.

Medical waste can be hazardous to healthcare workers and the general public if it is not disposed of safely and appropriately. If waste is not managed properly, there can be an increased risk of needlestick injuries. This problem is most prominent in developing countries where efforts to stop medical waste being sorted and repackaged for future sale are essential if the transmission of HIV is to be prevented.

Dhaka, Bangladesh, has particularly suffered from the lack of management for medical waste. A study in 2005 found an estimated 200 tons of waste came from Dhaka’s 600 healthcare establishments per day. It found that of the 60 of 68 establishments surveyed 22.6 percent of the daily waste was hazardous.127 Further to this very few establishments separated their waste into hazardous or non-hazardous waste to be disposed of separately and items such as needles, syringes, blood bags, and body parts were routinely disposed of as domestic waste.

Throughout developing countries the growing market for used needles and syringes has entrenched a process of recycling needles and syringes into communities.128 This process involves sorting through rubbish sites to collect medical waste and is often carried out by children. These needles and syringes are then repackaged and sold. In India a batch of rinsed syringes collected in this way can be sold for up to 10 rupees or 14 pence.129

The transmission of HIV among injecting drug users is a major route of transmission in many countries as a result of sharing needles and syringes. The need for harm reduction services such as needle and syringe exchanges prevents the sharing of equipment and limits the improper disposal of hazardous waste.

Conclusion

Boys collecting used needles and syringes on a rubbish site

Boys collecting used needles and syringes on a rubbish site

The parallel between blood safety and HIV cannot be overlooked. This route of transmission should be the easiest to combat, especially with the development of new technologies aiding health workers to practice safely. Using a new needle and syringe every time not only saves lives but is also far more cost-effective in the long-term, when considering the life-time medical costs associated with HIV treatment and care.130 131 132

Ending the use of unsafe blood and reuse of medical equipment requires an holistic approach, which should not only target healthcare workers, but also those who profit from the recycling of needles and syringes and those who profit from the collection and use of unsafe blood.

Countries who do not observe World Health Organisation recommendations must increase efforts to overcome the obstacles they face in the effort to make blood products and healthcare settings safe from HIV.

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Last updated August 16, 2010