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[e-drug] Policies to reduce HIV transmission through unsterile care

E-drug: Policies to reduce HIV transmission through unsterile care

[Cross-posted SIGNpost. With thanks. HH]

Four Policies to Reduce HIV Transmission through Unsterile Health

David Gisselquist, Eric Friedman, John J. Potterat, Steven F. Minkin,
Stuart Brody. Abridged with permission from Int J STD AIDS 2003;
14: 717-722.

We propose four policies for donors, governments, and NGOs to
adopt to ensure sterile practices in most healthcare exposures in
developing countries.

1. Educate the public about risks to contract HIV through health care:
Healthcare consumers - not only providers - need to know that
unsterile care is dangerous. At room temperature, HIV can remain
viable for hours in dry conditions[1] and for more than a week in wet
conditions[2], allowing delayed transmission through unsterilized
syringes, multi-dose vials, and rinsing pans. Documented HIV
transmission through health care shows HIV infecting 250 Russian
children in 1988-89[3], more than 1,000 Romanian children in the late
1980s[4], and almost 400 Libyan children in 1998[5].

Many people do not know that injections are a risk for HIV. For
example, in a 1996 survey, only 57% of Nigerian secondary students
knew that HIV could be transmitted through unsterilized
instruments[6]. Since people in developing countries - even and
especially poor people - choose among formal and informal providers
and pay for much of their health care out-of- pocket[7], people have
leverage to ask for safe care. Educating healthcare professionals is
important, but decades of experience prove it is not enough to assure
sterile care in many developing countries.

2. Promote transparent practices for injections and other common
healthcare procedures that allow patients to see and know that health
care is safe: For injections and other simple invasive procedures,
practices can be identified and promoted that allow patients (and
parents of young patients) to see that equipment is sterile and that
injected substances are not contaminated (aside from fraud or
product errors before packaging). An acronym for all such transparent
practices could be POST, for Patient Observed Sterile Treatment.

For example, to be sure that injections are safe, a patient could ask to
see the provider remove a new auto-disable syringe from a sealed
package and take the vaccine or medicine from a single-dose vial.
Defining and implementing POST practices can begin at any level. A
church, for example, may organize meetings between members and
local healthcare providers to discuss and endorse POST practices for
injections, dental care, etc. Some safe practices might boost costs,
but others might save money, such as oral or no medication instead
of injectable treatment for many common symptoms.

For some POST practices, donor and government cooperation may
be essential, such as to avoid multi-dose vials. A patient or parent
who sees a nurse withdrawing vaccine from a pre-opened vial may
wonder if previous withdrawals used sterile needles. One option is to
shift to single-dose vials and/or pre-loaded syringes, though cost and
capacity may be limiting in the short run. Governments could allow
private supply of single-dose vials for those who want to pay.
Technical solutions may also be found, such as redesigning multi-
dose vials to ensure no contamination.

3. Promote safe health care practices equally for clients and staff.
Many foreign and international organizations supporting healthcare
programs in developing countries advise staff that local health care is
unsafe. For example, a 1999 UNAIDS publication[8] encourages UN
employees to "carry sterile disposable needles and syringes for your
personal use (as part of the WHO medical kit)" and to "make sure
that all equipment is properly sterilized." This echoes POST, but only
for staff.

To avoid this double-standard, foreign organizations could insist that
the healthcare programs they support educate clients about risks with
unsterile care and promote POST practices for injections and other
simple health care procedures, so that clients - and not only staff -
can see and know that health care is safe.

4. Establish a zero-tolerance policy for HIV transmission through
health care. A zero-tolerance policy means that health officials:
monitor sterile conditions in healthcare settings through occasional
visits to collect and test ready-to-use sharps and opened multi-dose
vials; and look for and investigate unexplained HIV infections (e.g., in
children with HIV-negative mothers).

>From 1984, scores of HIV-infected African children with HIV-negative
mothers have been reported[9]. What has been strikingly absent in
Africa are thorough follow-up investigations to find all linked cases,
identify clinics and procedures involved, and make changes
necessary to stop transmission. To ensure investigations consistent
with zero-tolerance, foreign organizations may pre-commit a
percentage of their health aid budgets in each country to investigate
HIV infections suspected to come from health care whenever cases

Conclusion: In the WHO Constitution[10], members states recognize
the importance of "informed [public] opinion and active cooperation"
for better health. We urge public education, transparent sterile
procedures, equal advice to clients and staff, and zero-tolerance for
HIV transmission through health care.


1. MMWR. Recommendations for prevention of HIV transmission in
health-care settings. MMWR 1987; 36 (suppl 2): 3S-18S.

2. Moudgil T, Daar ES. Infectious decay of human immunodeficiency
virus type 1 in plasma. J Infect Dis 1993; 167: 210-212.

3. Bobkov A, Garaev MM, Rzhaninova A, Kaleebu P, Pitman R,
Weber JN, et al. Molecular epidemiology of HIV-1 in the former Soviet
Union: analysis of env V3 sequences and their correlation with
epidemiologic data. AIDS 1994; 8: 619-624.

4. Patrascu IV, Dumitrescu O. The epidemic of human
immunodeficiency virus infection in Romanian children. AIDS Res
Hum Retroviruses 1993; 9: 99-104.

5. Yerly S, Quadri R, Negro F, et al. Nosocomial outbreak of multiple
bloodborne viral infections. J Infect Dis 2001; 184: 369-372.

6. 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:

7. Berman P. Organization of ambulatory care provision: a critical
determinant of health system performance in developing countries.
Bull WHO 2000; 78: 791-802.

8. UNAIDS. AIDS and HIV Infection: information for United Nations
employees and their families. Geneva: UNAIDS, 1999.

9. Gisselquist D, Rothenberg R, Potterat JJ, Drucker E. HIV infections
in sub-Saharan Africa not explained by sexual or vertical
transmission. Int J STD AIDS 2002; 12: 657-666.

10. Constitution of the World Health Organization, WHO Bull 2002;
80: 983-984.

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