HIV PREVENTION: May 2012

Wednesday, May 30, 2012

Recommendations forpost-exposure prophylaxis

Recommendations forpost-exposure prophylaxis

Post-exposure prophylaxis should be
initiated ideally within 2 hours and no
later than 72 hours following exposure.
Issues relating to potential benefits,
unproven efficacy, potential side effects,
the need for adherence to the treatment
regime, signs and symptoms of primary
HIV infection as well as the need
for clinical and laboratory monitoring
and follow-up must be discussed.
The recommended protocol for postexposure
prophylaxis consists of
ziduvodine plus lamivudine together with
a protease inhibitor, all taken orally:
Alternatives to the first two drugs are:
􀂄 Instead of zidovudine use stavudine
– 40 mg twice daily for bodyweight
more than 60 kg, 30 mg daily if
bodyweight lower than 60 kg
􀂄 Instead of lamivudine use didanosine
- 400 mg daily if bodyweight more
than 60 kg, 250 mg daily if
bodyweight lower than 60 kg.
Before starting, blood should be taken
for full blood count (including differential
and platelets) and liver function tests.
These will serve as baselines for
monitoring of side-effects. Prophylaxis
should be taken for 4 weeks.
Follow-up care and support
P o s t - e x p o s u r e c a r e i n v o l v e s
simultaneous attention to multiple
issues: the emotional state of the
exposed patient, adherence to the postexposure
prophylaxis regimen,
monitoring for potential adverse effects
and sequential HIV testing to exclude
acquisition of infection.

(i). HIV Exposure through needlestick injuries.

(i). HIV Exposure through needlestick
injuries.
Needle-stick injuries in a non-health
care setting can prompt requests for
post-exposure prophylaxis. Factors to
consider in this instance include the
potential source of the needle, type of
needle, presence of blood and skin
penetration. Vaccination to prevent
tetanus may be indicated for needle
stick injuries resulting in puncture
wounds.
(ii). HIV exposure through bites.
Although possible, HIV transmission
following bites is thought to be extremely
rare. While there have been many
reported instances of bites, the few
documented cases of possible HIV
transmission following a human bite
exposure were in adults exposed to
blood-tinged saliva3 .
(iii). HIV exposure following sexual
assault.
Whenever possible, survivors of sexual
assault should be treated in an
emergency department where all
appropriate medical resources are
available. The recommendation for postexposure
prophylaxis should be
communicated simply and clearly to the
patient considering his/her emotional
state and ability to comprehend the
nature of the intervention. If the survivor
is too distraught to engage in a
discussion about whether to initiate
therapy or not, a first dose of medication
should be offered and arrangements
made for a follow-up appointment within
3 days. Starter-packs of medication
should be available on-site for rapid
initiation of post-exposure prophylaxis
following sexual assault. Emergency
contraception and sexually transmitted
infection(s) treatment have become part
of some standard medical protocols in
many countries4 .
Baseline testing for patients who
present with risk exposures.
Baseline HIV testing of the exposed
person should be done. Initiation of postexposure
prophylaxis should not be
delayed pending HIV test results.
Refusal to undergo baseline testingshould not preclude the initiation of postexposure
prophylaxis. The risks and
benefits of the intervention should be
carefully explained and on-going
counselling and support provided. Rapid
HIV testing is the preferred method of
testing in this situation because it can
immediately identify previously infected
persons and thus avoid unnecessary
risks from inappropriate initiation of postexposure
prophylaxis. Counselling and
referral for further care must be provided
for clients who test HIV-positive at baseline.

Antiretroviral prophylaxis following

Antiretroviral prophylaxis following
occupational exposure has been a
standard of care for health workers
since the 1980’s. Prophylaxis following
sexual exposure and other exposures
including injecting drug use has been
extensively considered and debated.
Practical guidelines and policy
recommendations for non-occupational
HIV prophylaxis must consider the
limitations of current scientific
knowledge and lack of definitive
evidence concerning efficacy to support
such recommendations.
Post-exposure prophylaxis should be
considered following non-occupational
exposures that include sexual assault,
needle sharing, trauma involving human
bites where there is exchange of
blood, condom breakage or other
exposures. Because there are no
randomized, placebo-controlled
clinical trials on which to definitively
base recommendations, current
recommendations are based on best
practice evidence and the considered
opinion of experts in this field. Several
studies also support the feasibility of
post-exposure prophylaxis1 .
There are many factors to consider
when deciding whether to implement
post-exposure prophylaxis or not.
A general and simple approach is that
whenever possible, risk assessment
and initiation of post-exposure
prophylaxis should occur in settings
where voluntary counselling and testing
services as well as HIV clinical
expertise are available or easily
accessible by referral. Clients should be
evaluated as soon as possible in order
for therapy to be initiated within the
recommended time-frames, which is
usually within 2 hours and no later than
72 hours after exposure.
When deciding whether to recommend
the initiation of post-exposure prophylaxis,
the clinician should assess the following
factors.
The circumstances that led to HIV
exposure
Assessment should include the
determination of whether the risk is an
isolated event, episodic event, or
habitual risk behaviour. Post-exposure
prophylaxis is recommended in
situations in which there is an isolated
exposure (sexual, needle or trauma);
however, it should not solely be
dismissed on the basis of repeated
high-risk behaviour(s). Persons who
present with repeated high-risk
behaviour(s) or for repeated courses of
post-exposure prophylaxis should be
the focus of intensified education and
prevention interventions.
Degree of transmission risk based
on type of exposure
Determining the degree of risk of HIV
transmission is an important factor in
guiding both patient and clinician in
making a decision concerning the
provision of post-exposure prophylaxis.
The health care provider should have a
frank discussion with the patient regarding
sexual activities, needle sharing and
other activities that have potential for
exposure to blood and body fluids2 .
Evaluation should also assess the
presence of other factors known to further
increase the risk of HIV transmission
such as trauma at the site of exposure,
and in cases of sexual exposure, the
presence of genital ulcers and/or other
sexually transmitted infections.

Injecting drug use is estimated to

Injecting drug use is estimated to
account for just less than one-third of new
infections outside Sub-Saharan Africa.
In spite of the importance of preventing
HIV among injecting drug users, coverage
of HIV prevention for this population is
at best 5% across the globe2 .
Beyond the physical risks associated
with drug injection, drug users are
vulnerable to HIV because of their social
and legal status. Ironically, in many
countries this means that HIV
interventions are not legally available to
drug users, or that drug users are
unable or unwilling to access them for
fear of recrimination or arrest.
Prisoners
Prisons are sites for drug use, unsafe
injecting practices, tattooing with
contaminated equipment, violence, rape
and unprotected sex. Conditions in most
prisons make them extremely high-risk
environments for HIV transmission,
leading them to be called ‘incubators’ of
HIV, hepatitis C and tuberculosis. They
are often overcrowded and offer poor
nutrition with limited access to health
care. Both male and female prisoners
often come from marginalized populations,
such as injecting drug users or sex
workers, who are already at increased
risk of HIV infection.
HIV prevention and treatment efforts in
prisons should be important components
of national AIDS strategies not only
because of the undoubted benefits in
public health terms but also as a matter
of fundamental human rights.
Furthermore, most prisoners at some
point return to the community. People
retain the majority of their human rights
when they enter prison, losing only
those that are necessarily and explicitly
limited because of incarceration. They
retain such rights as freedom from cruel
and inhuman punishment, and the right
to the highest attainable standard of
health care.
Over 20 years into the HIV response
these populations remain key to the
dynamics of the epidemic and continue
to be disproportionately infected with
HIV and affected by it. Unfortunately the
political and institutional commitment
required to address the economic,
social, gender and other disparities
which fuel AIDS epidemics and
exacerbates its impact on people with
these behaviours or in some settings
remains unacceptably low.
Enhanced leadership, resources and
prevention and even treatment
programmes will prove inadequate
unless the capacity of individuals and
communities to decrease their
vulnerability to infection is improved.
What is needed is a radical reorientation
of existing responses to HIV prevention
and impact mitigation; a refocused
approach to prevention that moves from
rhetoric about vulnerability to making
vulnerability reduction a priority.

Men who have sex with men

Men who have sex with men
In a few societies sex between men is
widely accepted; in some it is tolerated;
and in many it is the subject of strong
disapproval, legal sanctions and social
taboos. Official indifference or hostility
means that there are few prevention and
care programmes for men who have
sex with men in developing countries. It
also means that little research has been
undertaken to discover HIV prevalence
rates, how many men are at risk and how
best to provide them with the information
they need to protect themselves and
their sexual partners.
Sex between men, particularly anal
intercourse without a condom, is one
way in which HIV and other sexually
transmitted infections are transmitted.
Although HIV prevalence rates among
men who have sex with men are high in
some countries; due to the relative
invisibility of male to male sex, sex
between men may be an unrecognized
factor in national and regional epidemics.
Where HIV prevalence is low, focusing
prevention efforts on people with high
risk behaviours such as men who have
sex with men not only protects those
individuals but can contain the epidemic
at a fraction of the cost associated with
a generalized epidemic. Doing this
effectively requires support for both risk
and vulnerability reduction interventions.
Risk reduction activities might include
distributing condoms and lubricant
among men who have sex with men or
providing them with specifically targeted
education aimed at promoting safer sex.
Supporting gay and other men who have
sex with men to come together and to
organize themselves for social
networking, solidarity building and policy
advocacy can play an important part in
reducing their vulnerability.
Sex workers
Sex workers are key to the dynamics
of most HIV epidemics; the potential for
a large number of sexual partners
increases the likelihood of exposure to
HIV for sex workers and/or the
possibility of exposing others to HIV.
HIV prevention in the context of sex work
rests on a range of factors including thelegal and policy environments in which
sex work occurs; the legal, social and
economic status of sex workers; and
the capacity of sex workers to organize
themselves and to identify and
implement effective responses to the
challenges they face, including HIV.Although many countries criminalize sex
work and thereby subject the act of
buying or selling sex for money to
criminal sanction; sex workers have the
same human rights as everyone else,
particularly rights to education,
information, the highest attainable
standard of health, and freedom from
discrimination and violence, including
sexual violence.
Since the beginning of the AIDS
epidemic sex workers have organized
around health and human rights issues,
and as a result some sex worker
organizations have played a crucial part
in reducing HIV risk and vulnerability.

Vulnerability to HIV reflects an

Vulnerability to HIV reflects an
individual’s or community’s inability
to control their risk of HIV infection.
Poverty, gender inequality and
harassment from state officials,
including the police, are all factors that
can increase people’s vulnerability to
HIV infection. Many populations are
vulnerable to HIV. Women and girls,
young people, people living in poverty,
migrant labourers, people in conflict and
post-conflict situations, refugees and
internally displaced people all
experience situations where they haveless control over their HIV risk than
they should and programmes should
prioritize their HIV prevention needs.
Both risk and vulnerability need to be
addressed in planning comprehensive
responses to the epidemic. However,
for the most part HIV prevention efforts
continue to prioritize risk reduction over
vulnerability reduction. Examples include:
􀂄 programmes that provide information
to drug users about safe injecting
practices, but then governments jail
drug users for possessing clean
injecting equipment, which increases
their vulnerability to HIV;
􀂄 organizations, which provide sexual
health services to sex workers but
provide no protection from violence
or coercion to engage in unsafe sex, fail
in their duty to provide a comprehensive
range of interventions; and
􀂄 projects that seek to educate men
who have sex with men about HIV
transmission are undermined by the
criminalization of homosexuality, and
the consequent imprisonment and
violence that gay and other men who
have sex with men often experience
at the hands of police.
A human rights approach to HIV
All of these ‘programming failures’ are
in fact violations of fundamental human
rights. HIV prevention programmes
continue to be stalled and undermined
by these abuses, and assessments of
the effectiveness of particular interventions
continually fail to address the problem
of the abjectly hostile policy environment
for responding to AIDS in many countries.
As a result, human rights abuses of key
populations fuel infection and violations
of their rights follow infection,
exacerbating the impact of the epidemic.
Protecting the rights and interests of
individuals at greater risk of HIV
infection is therefore an important public
health intervention which can both help
stem the tide of new infections and
mitigate the impact of the disease.

S tatistics mask a deeper truth about HIV which points to important

S tatistics mask a deeper truth about
HIV which points to important
issues about inequality, vulnerability and
how best to fight the disease. The global
AIDS epidemic is composed of many
small, often overlapping epidemics that
reflect different patterns of risk and
vulnerability. The burden of HIV does not
fall evenly across the world but
concentrates its impact on regions
and populations, exacerbating the
impact of poverty, marginalization and
human rights violations. As a result,
within countries some groups are
disproportionately affected by HIV.
The term ‘key population’ is used to refer
to populations who are significant to the
dynamics of the epidemic in a particular
context. Depending on the country
context and the rate of prevalence, key
populations may include men who have
sex with men, sex workers, injecting
drug users and prisoners. In most
countries, these populations tend to
have a higher prevalence of HIV
infection than that within the general
population because they engage in
behaviours that put them at greater risk
of infection and they are among the
most marginalized and discriminated
against populations in society.
At the same time, the lack of resources
devoted to HIV prevention, treatment
and care for these populations are
disproportional to the number of people
living with HIV from these groups or the
impact of HIV on them. This is a serious
mismanagement of resources and a
human rights violation for individuals
from these groups.
Understanding risk and vulnerability
Understanding the difference between
risk and vulnerability is vital for people
involved in the HIV response.
HIV risk can be defined as the
probability of an individual becoming
infected by HIV either through his or her
own actions, knowingly or not, or via
another person’s actions. For example,
injecting drugs using contaminated
needles or having unprotected sex with
multiple partners increases a person’s
risk of HIV infection.

Tuesday, May 29, 2012

What are the living principles of a positive prevention strategy and how should these be put into practice?

What are the living principles of
a positive prevention strategy and
how should these be put into
practice?
The following four guiding principles
determine both the validity and content
of a positive prevention approach:
􀂄 Promotion of human rights: This
should ensure the right to privacy,
confidentiality, informed consent and
voluntary disclosure. Protection of
the rights of people living with HIV
needs to be guaranteed. Stigma and
discrimination – including self stigma
– drive people underground and
make prevention even more difficult.
A supportive and enabling legal
environment is a fundamental
cornerstone as it recognizes that
prevention strategies based on
coercion and criminalization are not
the answer.
􀂄 Involvement of people living with HIV:
People living with HIV must be
involved in the decisions relating to
their life. In accordance with the
Greater Involvement of People
Living with HIV (GIPA)3 Principle,
the active engagement of people
living with HIV in determining their
own unique prevention reality is key
to success in ensuring relevance,
efficacy and applicability.
􀂄 Embracing shared ownership and
responsibility: Of particular importance
is that positive prevention places the
responsibility for reducing HIV
transmission on everybody and
removes the undue burden on
people who are aware of their status.
Safer and responsible sexual
behaviour is the responsibility of all
partners – irrespective of status.
Promoting a culture of shared
responsibility could also improve
communication and equality within
relationships.
􀂄 Recognition of diversity: People
living with HIV are heterogeneous
and represent a cross section of all
sectors of society. Issues of race,
ethnicity, gender, orientation, age,
language, and risk profile will all have
an effect on how positive prevention
initiatives need to be tailored.
What positive prevention is and
what it is not
While there is consensus on what the
purpose of positive prevention is, there
is still a lack of coherence on the actual
term. Some have referred to it as
‘prevention for positives,’ ‘prevention
interventions for people living with HIV’
and ‘prevention for by and with people
living with HIV.’ The term ‘positive
prevention’ is at times also confused
with the development of upbeat and
supportive mainstream and primary
prevention messages aimed at
predominantly HIV-negative people.
Irrespective of the term used, the four
building blocks of a positive prevention
approach aim to proactively address the
sexual and health needs of people living
with HIV.

Why is positive prevention needed now?

Why is positive prevention needed
now?
Since HIV made its debut on the
international stage over 25 years ago,
much has been learnt about prevention.
Knowledge about HIV transmission and
the role of key interventions to prevent
HIV transmission from mother-to-child
and harm reduction initiatives for
injecting drug users have dramatically
altered the prevention landscape.
However, in the face of increased
treatment and the key to sustained
behaviour change(s) remaining largely
elusive, HIV prevention fatigue is a
reality which has not been adequately
addressed. The weariness of both the
“post-AIDS” generation for whom past
hard won battles have little meaning as
they explore their sexuality and for those
who have reaped the rewards of
antiretroviral therapy are realities that
our prevention efforts need to address
more boldly.
‘Traditional’ prevention efforts have
largely targeted those who are HIVnegative,
and obviously this is crucial,
yet it ignores the needs, and important
role, of those who are HIV positive. The
assumption that knowledge of HIV
status alone will ensure sustained safer
sex practice has been called into
question by the increasing number of
new infections in key populations where
HIV had appeared to have stabilized.
The HIV prevention agenda needs to
keep pace with these new and dynamic
demands of the epidemic – and this
includes responding to the reality of
treatment access, the increasing
number of serodiscordant relationships
and the importance of addressing the
specific prevention needs of people
living with HIV. Encouraging and
supporting people living with HIV to live
‘positively’ includes a strong recognition
that issues of love, life and intimacy are
part of their reality.
HIV-positive people – the vast majority
of whom are unaware of their status -
are the nexus for future infections and
to exclude them from dedicated
prevention efforts is not conducive to
successful global prevention. By
building on the lessons that have been
learnt about strengthening the links
between HIV prevention, and AIDS
treatment, care and support into a
seamless continuum and about the
imperative of a human rights-based
approach towards HIV, the addition of
‘positive prevention’ initiatives will create
cohesiveness to ensure that the sum
of the parts is greater than each
individual component.
What is positive prevention?
Positive prevention can be defined2 as
a set of actions that help people living
with HIV to:
􀂄 protect their sexual health;
􀂄 avoid other sexually transmitted
infections;
􀂄 delay HIV and AIDS disease
progression; and
􀂄 avoid transmitting HIV to others.Positive prevention is based on the
realities and perspectives of people
living with HIV and it acknowledges that
every individual has a right to a
productive, satisfying and enjoyable
sexual (and reproductive) life. This
necessitates the development of explicit
information that can inform the choices
that people living with HIV (and their
sexual and recreational partners) make.
Ownership of positive prevention
approaches depend and rely upon
individual action.

HIV prevention can never be effective

HIV prevention can never be effective
without AIDS treatment, care and
support components. The SAVE model
combines HIV prevention and AIDS
treatment, care and support components,
as well as providing messages to
counter stigma.
The adoption of SAVE does not imply
the abandonment of abstinence. The
‘S’, for ‘safer practices’ includes
abstinence as well as a wide range of
evidence-based HIV prevention
interventions such as safe blood for
blood transfusion; barrier methods
for penetrative sexual intercourse;
sterile needles and syringes for
injecting; safer methods for scarification
and adoption of universal medical
precautions. While abstinence remains
a reliable method of avoiding exposure
to sexually transmitted infections, it must
not be taught in isolation. It is vital that
information is always available on a wide
range of evidence-based HIV prevention
interventions.
‘A’ refers to available medications.
Antiretroviral therapy is by no means the
only medical intervention needed by
people living with HIV. Long before it may
be necessary, or desirable, for a person
to commence antiretroviral therapy, some
HIV-related opportunistic infections will
need to be treated. Treatment of these
infections results in improved quality of
life, better health and longer term survival.
Furthermore, every person needs good
nutrition and clean water, and this is
doubly true for people living with HIV.
‘V’ refers to voluntary counselling and
testing. Individuals who know their HIV
status are in a better position to protect
themselves from infection; and if they
are HIV-positive, from infecting others.
People who know that they are HIVpositive
can be provided with information
and support to enable them to live
positively. Those who know that they
are HIV-negative may have an incentive
to adhere to ‘S’. People, who are
ignorant of their HIV status or who are
not cared for, are more vulnerable and
can be potential sources of new HIV
infections.
‘E’ refers to empowerment through
education. It is not possible to make
informed decisions about any aspect of
HIV or sexual or other behaviours
without access to all the relevant facts.
Inaccurate information and ignorance
are two of the greatest factors driving
HIV-related stigma and discrimination.
Correct, non-judgmental information
needs to be disseminated to all, inside
and outside churches. This will assist
people to live positively – whatever their
HIV status – and to break down barriers
which HIV has created between people
and within communities. Education also
includes information on good nutrition,
stress management and the need for
physical exercise.
HIV is a virus. The development and
implementation of HIV preventive
strategies should be based on public
health measures and human rights
principles. The behavioural patterns that
make people susceptible to HIV may
have moral implications. Strengthening
the value systems in communities
without simplistic moralization is vital to
enhancing prevention strategies.
However, working against scientifically
proven preventive measures is both
unethical and detrimental to life.

HIV prevention have had the

B ut some of the messages used for
HIV prevention have had the
unfortunate consequence of adding to
the stigma surrounding HIV. In some
respects, ABC is one such message.
ABC has proven less than ideal to
address the complexities of human life,
as it does not take into account the
critically important issue of gender. It
has failed to address masculinity, and
its often harmful and violent expression.
It avoids the reality of women being
deprived of their right to negotiate sexual
relationships. Some women’s
empowerment programmes for HIV
prevention have also added to the
existing burden on women as safe sex
negotiation strategies have become
their exclusive responsibility.
While abstinence may be appropriate at
some stages of life and faithfulness is
for many people the preferred choice,
they both unfortunately do not guarantee
protection against infection in the
community setting. There is no question
of the validity and the importance
of abstinence and faithfulness.
But highlighting these at the cost of
comprehensive and holistic prevention
strategies will not help us address the
root causes of HIV.
According to some interpretations of
ABC, the use of a condom automatically
puts a person in the category of one who
cannot be faithful or does not want to
abstain. This fuels stigma and precludes
safer sexual practices. Though the ABC
approach itself has its limitation, it is
sometime further truncated by some
faith communities who, having problems
accepting the role of condoms in
prevention, conveniently drop the ‘C’.
A limited ABC strategy becomes a
further compromised AB!
Many regions have a serious problem
of HIV transmission through injecting
drug use. The ABC completely
precludes dealing with this route of
transmission and other significant
routes of infection such as – mother-tochild
transmission and unsafe blood
transfusions. The strategy is also
incapable of addressing the social
issues such as poverty and the role of
harmful traditions and practises in HIV
transmission. The ABC approach is
also didactic and less open to dialogue
and participation of people living with
HIV. Many proponents get carried away
and seem to be quite sure about what
“we” are able to do for “them”.
Perspectives also become skewed
when faith communities talk to one
another, excluding other civil society
players, resulting in “I scratch your back
and you mine... I will ask you what youwant to respond to and you will answer
what I want to hear!”
As the AB approach now has many
proponents and sources of funding, it is
for faith communities to ask themselves
difficult and incisive questions, and
search for more comprehensive
alternatives.
The way forward
The African Network of Religious
Leaders Living with or personally
affected by HIV and AIDS (ANERELA+)
has developed a new model for a
comprehensive HIV response,

Churches have been in the forefront of

Churches have been in the forefront of
care for people living with HIV. In many
countries, churches provide much of
the available health care and are
important collaborators when it comes
to ensuring that HIV prevention isintegrated into the health and care
services they provide.
As the international community focuses
on scaling up towards universal access
to HIV prevention, and AIDS treatment,
care and support, churches and their
health care institutions must be key
partners in the development and
achievement of country-level targets,
action plans and the roll out of
implementation activities. Furthermore,
as and when, new prevention
technologies such as microbicides and
vaccines become available, they will
need to play a major role in promoting
their acceptance. Many churches have
characteristically worked in relative
isolation, often in remote rural
communities. Today the international
community looks to work in collaboration
and partnership with communities of
faith and recognizes the importance of
their contribution.
As HIV is mainly a sexually transmitted
virus and as sexuality is a difficult topic
to discuss, UNAIDS is encouraged by
the innovative ways some churches
handle these issues. One church,
realizing that infidelity often was due to
sexual boredom in marriage, arranges
meetings in which married couples can
discuss this problem, and how to repair
and enhance sexual relations within the
married couple. Many Christian-based
organizations have made efforts to beinvolved in HIV prevention,
for example, World Relief,
which has produced very
comprehensive information
material on human sexuality2 .
HIV will change the world, and
we are already seeing this
happening in the hardest hit
countries. Many churches
have begun internal work on
transformation in order to be
able to respond to this
changed world. UNAIDS
welcomes this process of
reflection and transformation
among churches to be more
relevant to changing times.

F ighting stigma and discriminationc

F ighting stigma and discrimination
against vulnerable groups and
people living with HIV, and ensuring their
inclusive participation in all aspects of
the response is key to turning around
the epidemic. UNAIDS welcomes the
World Council of Churches (WCC)
statement that “stigma and discrimination
of people living with HIV is a sin and
against the will of God ”. If this statement
is put into practice, churches would be
helping immensely in efforts to eradicate
the unjust exclusion of people living with
HIV from day-to-day life.
Churches can be and in many cases
already are forceful actors in the fieldof HIV prevention. While UNAIDS
is already collaborating with faithbased
organizations worldwide and
has extensive collaboration with the
WCC and individual churches, it seeks
to broaden this partnership in the
coming years. While recognizing that
on some issues we differ, we have a
common understanding of the need to
both promote abstinence and
faithfulness and help people to identify
situations of risk and take steps to
protect themselves from HIV when
these occur.
Churches must become the trusted
source for accurate information to
members about human sexuality. Such
knowledge is required to understand
HIV and how to prevent HIV transmission.
We are inspired by the many churches
who work with marginalized populations
such as drug users and sex workers,
and young people as valuable partners
in addressing issues of risk and
vulnerability, providing education, and
often have a sound knowledge of how
to work with these groups.

A s early as 1986 the Executive

A s early as 1986 the Executive
committee of the World Council of
Churches (WCC) stated:
to confess that churches as
institutions have been slow to speak
and to act, - that many Christians
have been quick to judge and
condemn many of the people who
have fallen prey to the disease; and
that through their silence, many
churches share responsibility for the
fear that has swept our
world more quickly
than the virus itself
“and called on the
churches to respond
appropriately to the
need for pastoral care,
education for prevention
and social ministry” 2.
In September 1996, a
landmark, comprehensive
statement, the Impact
of HIV/AIDS and the
Churches’ Response,
was adopted by the
WCC Central Committee
on the basis of the
WCC Consultative
Group on AIDS study
process.3 The statement
clearly states that:
Churches can do
much to promote, both
in their own lives and
in the wider society, a
climate of sensitive,
factual and open
exploration of the
ethical issues posed
by the pandemic. … in accordance
with their emphasis upon personal
and communal responsibility the
churches’ can promote conditions –
personal, cultural, and socioeconomic
– which support persons
in making responsible choices. This
requires a degree of personal
freedom which is not always
available: for example, women, even
within marriage, may not have the
power to say “no” or to insist on the
practice of such effective preventive
measures such as abstinence,
mutual fidelity and condom use.
The statement went on to assert:
People living with HIV generally
encounter fear, rejection and
discrimination. Because such
reactions contradict the values of the
gospel, the churches are called to
formulate and advocate a clear policy
of non-discrimination against
persons living with HIV/AIDS.

Monday, May 28, 2012

Anyone can become infected with HIV

Who needs HIV prevention?

Anyone can become infected with HIV, and so promoting widespread awareness of HIV through basic HIV and AIDS education is vital for preventing all forms of HIV transmission. Specific programmes can target key groups who have been particularly affected by a country’s epidemic, for example children, women, men who have sex with men, injecting drug users and sex workers. Older people are also a group who require prevention measures, as in some countries an increasing number of new infections are occurring among those aged over 50.³

HIV prevention needs to reach both people who are at risk of HIV infection and those who are already infected:

People who do not have HIV need interventions that will enable them to protect themselves from becoming infected.
People who are already living with HIV need knowledge and support to protect their own health and to ensure that they don’t transmit HIV to others - known as “positive prevention”. Positive prevention has become increasingly important as improvements in treatment have led to a rise in the number of people living with HIV.⁴ ⁵ ⁶

HIV counselling and testing are fundamental for HIV prevention. People living with HIV are less likely to transmit the virus to others if they know they are infected and if they have received counselling about safer behaviour. For example, a pregnant woman who has HIV will not be able to benefit from interventions to protect her child unless her infection is diagnosed. Those who discover they are not infected can also benefit, by receiving counselling on how to remain uninfected.⁷ ⁸ ⁹

The availability and accessibility of antiretroviral treatment is crucial; it enables people living with HIV to enjoy longer, healthier lives, and as such acts as an incentive for HIV testing. Continued contact with health care workers also provides further opportunities for prevention messages and interventions. Studies suggest that HIV-positive people may be less likely to engage in risky behaviour if they are enrolled in treatment programmes.¹⁰ ¹¹

Conclusion

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.¹³³ ¹³⁴

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.

Medical waste and HIV

Searching for needles and syringes by hand

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.¹³⁰ 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.¹³¹ 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.¹³²

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.

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 Organization¹²⁷ 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. ¹²⁸ 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.¹²⁹

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.

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.¹²¹

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 1000.¹²² 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.

Occupational exposure and HIV

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 intact skin is exposed to HIV infected blood then there is no risk of HIV transmission"

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

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.¹²⁴

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. ¹²⁵

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.

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.¹¹⁵ 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.¹¹⁶

WHO estimates that up to 70 percent of injections in some countries, were 'medically unnecessary'.¹¹⁷ ¹¹⁸ For example, in some countries injections are given unnecessarily to administer antibiotics or vitamins.¹¹⁹ ¹²⁰ 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.

Sunday, May 27, 2012

The Indian government issued a mandate

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.¹⁰⁴ Despite the phasing out of sterilizable and disposable syringes by some international organizations and governments, both continue to be used instead of AD syringes.¹⁰⁵ 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.¹⁰⁶ 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.

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".¹⁰⁷ 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).¹⁰⁸ ¹⁰⁹ UNICEF mass vaccination campaigns can vaccinate an estimated 10 million children in one week and they use only AD syringes.¹¹⁰

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. ¹¹¹ ¹¹² This resulted in 40,000 people requiring tests for HIV, hepatitis C and B.¹¹³ 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.11

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"⁷²

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 body⁷³ and it has been found that syringes containing HIV infected blood can still transmit HIV, even after being rinsed, for up to 4 weeks.⁷⁴ Studies have illustrated the parallel between the re-use of equipment and infection with blood borne viruses.⁷⁵ ⁷⁶

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.⁷⁷ Gross re-use of medical equipment, including syringes, was reported in three of Kazakhstan's Hospitals in 2007.⁷⁸ 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 1991.⁷⁹

Health systems must be strengthened to provide healthcare workers with training and resources if injections are to be made safer.⁸⁰ ⁸¹ 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.⁸² 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.⁸³ ⁸⁴ ⁸⁵ ⁸⁶ ⁸⁷ ⁸⁸ However, WHO estimates for sub-Saharan Africa are far more conservative at 2.5 percent.⁸⁹ ⁹⁰ They uphold that although HIV transmission in healthcare settings, notably medical injections, is an area of concern, most infections are sexually transmitted.⁹¹

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.⁹²

The Safe Injection Global Network (SIGN)⁹³ 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.⁹⁴ 'Making Medical Injections Safer' (MMIS)⁹⁵, 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.⁹⁶ 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.⁹⁷

Technology such as single dose, pre-filled Auto-Disable (AD) injection devices (used for vaccinations) and AD syringes⁹⁸, which have a one-way valve making the syringe useless after one use, have the potential to make injections in developing countries safer.⁹⁹ ¹⁰⁰ ¹⁰¹ 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.¹⁰² However, vaccinations only account for 10 percent of injections whereas 90 percent are for curative (or treatment) purposes

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.⁵⁶ ⁵⁷ 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.⁵⁸

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 13 times higher.⁵⁹ 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.⁶⁰ ⁶¹

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.⁶² 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'.⁶³ ⁶⁴ 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.⁶⁵ ⁶⁶ A lack of safe blood in southern Africa accounts for an estimated 15 percent of anemia related child deaths⁶⁷ ⁶⁸ and 44 percent of maternal deaths are due to hemorrhaging during pregnancy in sub-Saharan Africa.⁶⁹ ⁷⁰

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)⁷¹ will not be achieved without persistent efforts by individual countries to develop safe and sustainable blood supplies.

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).⁴⁷ UNAIDS figures show only half of Pakistan's annual 1.5 million bags of transfused blood are screened⁴⁸ and it is believed that 19 percent of new HIV infections in Pakistan are due to unsafe blood.⁴⁹ ⁵⁰ 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.⁵¹ 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.⁵²

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.⁵³ 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.⁵⁴ ⁵⁵ 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.

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.³⁷ 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.³⁸

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.³⁹

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.⁴⁰ 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. ⁴¹ 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.⁴² ⁴³

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. ⁴⁴ ⁴⁵ The WHO asserts this is reliant on the formulation and implementation of a national blood policy by a country's government.⁴⁶

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.¹⁷ For example, 70 percent of donations in Pakistan are from 'family and replacement' donors with a further 10 percent of donations from paid donors.¹⁸ 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.¹⁹

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.²⁰ ²¹

The most recent reported case in the US of HIV being transmitted through transfusion occurred in 2008.²² This followed a six year period whereby there were no reported HIV transmissions through transfusion. HIV transmission occurred in this case, firstly because the routine donor (and therefore often considered the safest type of donor) answered incorrectly to questions about high-risk behaviour during the donor screening questionnaire and secondly, due to being recently infected the donor was in the window period (approximately 12 days when tests are unlikely to detect HIV) which resulted in the infected blood being used.

The importance of donors answering honestly to eligibility questionnaires is emphasised by this case. It was highlighted by the CDC that although the risk of HIV transmission through blood transfusion is extremely unlikely in the United States, it should not be ruled out as a possible route for HIV transmission.²³

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.²⁴

"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.²⁵ ²⁶ ²⁷ ²⁸ ²⁹ Organisations such as the American Red Cross support a deferral rather than a lifetime ban for MSM.³⁰ 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.³¹ 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.³²

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.³³ ³⁴ 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.³⁵

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

One of the primary routes of HIV transmission

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.

Saturday, May 26, 2012

Details of the WHO PMTCT and breastfeeding guidelines

Mothers, when identified in pregnancy as being HIV positive, should have a CD4 test to determine whether they need to take medication for their own health or for their unborn infant’s health. If their CD4 count is below or equal to 350 cells/mm³ they need to start taking antiretroviral drugs for their own health. If a woman has a CD4 count higher than 350 cells/mm³ then they do not need to take medication for their own health. However, they will need to take medication to prevent HIV transmission to their infant(s).

Mother taking ARVs (antiretroviral drugs) for her own health

A mother taking ARVs for her own health should take a combination of ARVs as soon as possible. This course of medication should be permanent and taken every day in order to postpone the development of her illness. In this situation, if an infant is being breastfed they should have daily NVP (nevirapine) for 6 weeks.

Mother taking ARVs for her infant’s health

There should be two drug combination options. The first option, Option A, closely resembles the WHO’s 2006 recommendations and might be a system already in place at country level. However, option B is a simple regimen for health providers and mothers to implement. It is considered that both options have advantages and disadvantages in terms of feasibility, acceptability, cost, and safety for both mother and infant. The choice for a preferred option should be made at a country level.

Infants

All infants born to HIV positive mothers should receive a course of medication for PMTCT, which is linked to the drug regimen that the mother is taking. If a mother is permanently taking ARV medication, the infant should receive daily NVP for 6 weeks. If the mother’s medication course is option A, the infant should receive daily NVP until one week after breastfeeding has ended.

If a child is being breastfed then this should be up to 6 months. After this a mother should supplement her breast milk with complementary feeding and all breastfeeding should be stopped by 12 months of life. Mothers are no longer advised to rapidly wean.

If an infant is not breastfeed, they should be given daily NVP or AZT (zidovudine) for 6 weeks

issued new HIV and AIDS guidelines on PMTCT

In July 2010, the World Health Organization (WHO) issued new HIV and AIDS guidelines on PMTCT (preventing mother to child transmission) and on HIV and breastfeeding.¹ For both PMTCT and for infant feeding there are major differences between these 2010 recommendations and the previous guidance issued in 2006.

Under the 2010 guidelines, all HIV positive mothers, identified during pregnancy, should receive a course of antiretroviral drugs to prevent mother to child transmission. All infants born to HIV positive mothers should also receive a course of antiretroviral drugs and should be exclusively breastfed for 6 months and complementary fed for up to a year.

Previous guidelines, issued in 2006, recommended that only women with a low CD4 count should receive a combination of HIV and AIDS drugs to prevent mother to child transmission and all HIV positive mothers were advised to exclusively breastfeed for 6 months and then rapidly wean to avoid transmitting HIV to their infant.²

For infant feeding, where resources are limited, health providers are recommended to continue using the 2006 guidelines.³ For more details about the 2006 guidelines, please see AVERT’s breastfeeding and HIV page.

International PMTCT initiatives

There are a number of large-scale international initiatives to prevent mother-to-child transmission of HIV. These include:

The President's Emergency Plan for AIDS Relief (PEPFAR)
MTCT-Plus
The Global Fund
The Call to Action Project
The UN Interagency Task Team on MTCT

The President's Emergency Plan for AIDS Relief (PEPFAR)

On June 19th 2002, US President Bush announced a new $500 million International Mother and Child HIV Prevention Initiative to prevent the transmission of HIV from mothers to infants and to improve health care delivery in Africa and the Caribbean. The Initiative was later integrated into the President's Emergency Plan for AIDS Relief (PEPFAR). In 2008 PEPFAR was reauthorized with the original $ 15 billion funding now tripled to $ 48 billion over the next five years.

The original Initiative had the aim of reaching one million women with HIV testing and counselling and providing preventive drugs to 80 per cent of HIV positive delivering women by 2007. It aimed to reduce mother-to-child transmission by 40 percent in its fourteen focus countries, twelve of which are in Africa.

From fiscal year 2004 to FY 2007, PEPFAR has supported prevention of MTCT for women during more than 10 million pregnancies with antiretroviral drugs being provided in over 827,000 pregnancies. This has resulted in the prevention of an estimated 157,000 infant HIV infections. ²⁶

AVERT.org has more information about the President's Emergency Plan for AIDS Relief in our PEPFAR page.

MTCT-Plus

The MTCT-Plus Initiative was established in 2002, and is coordinated by the Mailman School of Public Health at Columbia University. The Initiative aims to move beyond interventions aimed only at preventing infant HIV infection. It does this by supporting the provision of specialised care to HIV-infected women, their partners and their children who are identified in MTCT programmes. Funding for the initiative is provided by a group of private foundations, including the Gates Foundation, the Kaiser Family Foundation and the Rockefeller Foundation, as well as by PEPFAR via USAID.

The MTCT-Plus Initiative provides operational funding, medications, training and technical assistance at 13 sites in sub-Saharan Africa and at one site in Thailand. Since its inception MTCT-Plus has provided care and treatment to more than 16,000 adults and children. ²⁷

The Global Fund

The Global Fund to Fight AIDS, Tuberculosis and Malaria is a public-private partnership that distributes grants worldwide to fund HIV/AIDS prevention and treatment programmes. Grants are distributed over two years and most countries receive some grants to fund PMTCT programmes.

In 2008 the Global Fund announced that 271,000 HIV positive pregnant women had been reached with prophylaxis for PMTCT through Global Fund money in 2007.²⁸

AVERT.org has more about The Global Fund.

The Call to Action Project

The Elizabeth Glaser Pediatric AIDS Foundation initiated the Call to Action Project (CTA) in September 1999 to help reduce MTCT of HIV in resource poor countries. The CTA is a public-private partnership that receives funding from both private sources such as the Gates Foundation and government grants. CTA has worked or is now working at approximately 400 sites in nineteen countries worldwide, of which twelve are in Africa.

The Foundation joined up with USAID in 2002 to rapidly expand PMTCT programmes. Programmes that were funded by USAID are now part of PEPFAR, while other CTA sites are still supported with private funding. By the end of 2003, the Call to Action project had trained over 5,000 healthcare workers and provided voluntary counselling to more than 625,000 women. As of March 31st 2008, the project had reached more than 5.2 million women with access to PMTCT services and had also provided more than 4.3 million women with HIV tests.

As off September 2010, the Call to Action Project will transition into other mechanisms. ²⁹

The UN Interagency Task Team on MTCT

The UN Interagency Task Team on MTCT involves UNICEF, UNFPA, WHO, the World Bank and the UNAIDS Secretariat and works with the governments of various low and middle-income countries to set up PMTCT programmes. In 2004, the Inter-agency partnership became known as "Children and HIV and AIDS," to reflect a broader understanding of how AIDS affects children.

HIV positive pregnant women not accessing drugs include:

Challenges faced by PMTCT programmes

Even where PMTCT services are available, not all women receive the full benefit. Reasons for HIV positive pregnant women not accessing drugs include:

Not being offered an HIV test
Refusing to take an HIV test
Not returning for follow up visits
Not adhering to self-administered drugs

HIV testing is critical because women who do not know they are HIV positive cannot benefit from interventions. In 2009 an estimated 26% of the estimated 125 million pregnant women in low and middle-income countries received an HIV test.²¹ However some women refuse to be tested because they fear learning that they have a life-threatening condition; because they distrust HIV tests; or because they do not expect their results to remain confidential, and fear stigma and discrimination following a positive result.

Women having tested negative early in pregnancy can become infected during pregnancy; without returning to clinics for retesting treatment is not accessed²² . Sometimes women who test HIV positive do not return to clinics for follow up visits, or fail to take the drugs they have been given. This can happen because they have had negative experiences interacting with clinic staff, fear or stigma or disclosure and because they did not receive adequate HIV counseling. because they have been poorly informed about HIV transmission and how it can be prevented. Fear of disclosure is a common reason why women are reluctant to return to their HIV clinic. In the words of a woman from Cote d'Ivoire:

"My husband might see me with the medicines, and he will want to know what they are for. That way he will find out about my [HIV positive test] result. Even the location bothers me, because everyone who comes to the clinic knows what goes on [at the programme]. As soon as a pregnant woman is seen coming here, it's known right away that she is seropositive."²³

One of the major problems in preventing mother-to-child transmission, it has been argued, is making the provision of ARV drugs the focus of PMTCT efforts. Access to other services such as counselling, care and treatment services, infant-feeding guidance, and in particular sexual and reproductive health is ignored as a result.²⁴ Therefore, it should not be assumed that the proportion of HIV-positive pregnant women who are receiving antiretroviral prophylaxis to prevent their child becoming infected - estimated at one-third in low and middle-income countries - are receiving comprehensive PMTCT services.²⁵

To achieve a high success rate, PMTCT programmes must have well-trained, supportive staff who take great care to ensure confidentiality. They must be backed up by effective HIV testing and counselling programmes and by good quality HIV/AIDS education, which is essential to eliminate myths and misunderstandings among pregnant women, and to counter stigma and discrimination in the wider community. Under these conditions, antiretroviral drugs have the potential to save many thousands of babies' lives.