HIV This Week

Ganczak M, Barss P. Nosocomial HIV infection: epidemiology and prevention-a global perspective. AIDS Rev. 2008;10(1):47-61.

Because, globally, HIV is transmitted mainly by sexual practices and injection drug use and because of a long asymptomatic period, healthcare-associated HIV transmission receives little attention even though an estimated 5.4% of global HIV infections result from contaminated injections alone. It is an important personal issue for healthcare workers, especially those who work with unsafe equipment or have insufficient training. They may acquire HIV occupationally or find themselves before courts, facing severe penalties for causing HIV infections. Prevention of blood-borne nosocomial infections such as HIV differs from traditional infection control measures such as hand washing and isolation and requires a multidisciplinary approach. Since there has not been a review of healthcare-associated HIV contrasting circumstances in poor and rich regions of the world, the aim of this article is to review and compare the epidemiology of HIV in healthcare facilities in such settings, followed by a consideration of general approaches to prevention, specific countermeasures, and a synthesis of approaches used in infection control, injury prevention, and occupational safety. These actions concentrated on identifying research on specific modes of healthcare-associated HIV transmission and on methods of prevention. Searches included studies in English and Russian cited in PubMed and citations in Google Scholar in any language. Medical Subject Headings (MeSH) keywords such as nosocomial, hospital-acquired, iatrogenic, healthcare associated, occupationally acquired infection and HIV were used together with mode of transmission, such as "HIV and haemodialysis". References of relevant articles were also reviewed. The evidence indicates that while occasional incidents of healthcare-related HIV infection in high-income countries continue to be reported, the situation in many low-income countries is alarming, with transmission ranging from frequent to endemic. Viral transmission in health facilities occurs by unexpected and unusual as well as more frequent modes. HIV can be transmitted to patients and to donors of blood products by specific vehicles and vectors during blood transfusion, plasma donation, and artificial insemination, by improperly sterilized sharps, by medical equipment during activities such as dialysis and organ transplantation, and by healthcare workers infected by occupational exposure to hazards such as blood-contaminated sharps. Personal, equipment, and environmental factors predispose to acquisition of nosocomial HIV and all are pertinent for prevention. For infection and injury control, poverty is often an underlying determinant. While sophisticated new tests offer improved HIV detection, increasingly higher marginal costs limit their feasibility in many settings. Modest investment in safer equipment and appropriate integrated training in infection control, injury prevention, and occupational safety should provide greater benefit.

Editors' note: Nosocomial (from the Greek nosos [disease] and komein [to care for] and later from the Latin for hospital nosocomium) infections are those that occur more than 48 to 72 hours after a patient is admitted and were not present or incubating at entry. This exhaustive review, the first in 15 years, is essential reading for policy makers, health personnel, and the public alike. The detailed descriptions of modes of health care-associated HIV transmission and of virtually all the documented cases from around the world set the stage for recommended interventions to eliminate/reduce risk for all countries, with special priorities for low-income countries. Arguing that prevention begins when everyone accepts that nosocomial infections are truly avoidable, the authors call for international action to develop and implement appropriate and efficient safety equipment, training, and surveillance that are feasible for even remote areas of low-income countries.

Paid plasma donation has contributed to HIV epidemics in many countries. Eleven million litres of plasma are fractionated annually in the U.S., mainly from paid donors. Deferral of high-risk donors such as injecting drug users is required for paid donations. Volkow and colleagues studied circumstances surrounding paid plasma donation among injecting drug users in two Mexico-U.S. border cities. In 2005, injecting drug users >/=18 years old in Tijuana (N=222) and Cd. Juarez (N=206) who injected in the last month were recruited through respondent-driven sampling. Subjects underwent antibody testing for HIV and HCV and an interviewer-administered survey including questions on donating and selling whole blood and plasma. Of 428 injecting drug users, HIV and HCV prevalence were 3% and 96%, respectively; 75 (17.5%) reported ever having donated/sold their blood or plasma, of whom 28 (37%) had sold their plasma for an average of $16 USD. The majority of injecting drug users selling plasma were residents of Ciudad Juarez (82%); 93% had sold their plasma only in the U.S. The last time they sold their plasma, 65% of injecting drug users had been asked if they injected drugs. Although the median time since last selling plasma was 13 years ago, 3 had done so within the prior 2 years, one within the prior 6 months; of these 3 injecting drug users, 2 were from Cd. Juarez, one from Tijuana; all 3 had only sold their plasma in the U.S. Although selling plasma appears uncommon among injecting drug users in these two Mexican border cities, the majority sold plasma in the U.S. and only one-third were deferred as high-risk donors. Paying donors for plasma should be a matter of public inquiry to encourage strict compliance with regulations. Plasma clinics should defer donors not only on behavioural risks, but should specifically inspect for injection stigmata.

Editors' note: Selling of blood and plasma was banned in Mexico over two decades ago but, surprisingly, remains legal in some US states such as California and Texas. High-risk donors are screened and deferred and pasteurisation or detergent treatment is used to inactivate potential blood-borne pathogens. Understandably, plasma donors in a paid donation system tend to be over-represented by economically disadvantaged persons who may be at higher risk of HIV exposure. Since deferral and plasma treatment are not fail-safe, all countries should move as quickly as possible to voluntary blood and plasma donations, promoted as part of civic duty rather than for monetary recompense.