HIV This Week

Progress in Global Blood Safety for HIV

Takei T, Abu Amin N, Schmid G, Dhingra-Kumar N, and Rugg D, J Acquir Immune Defic Syndr, 2009;52(S2)

The aim of the report was to assess progress towards ensuring a globally safe blood supply. The authors examined 2 global databases for blood safety: that of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) blood safety indicator; and that of the Global Database on Blood Safety (GDBS), a database developed by the World Health Organization. The UNGASS data were collected through the Ministry of Health based on the GDBS data, followed by a reconciliation and cross-checking of the data by World Health Organization and United Nations Programme on AIDS (UNAIDS). They found that the proportion of United Nations member countries reporting UNGASS data for blood safety is among the highest of all UNGASS indicators: 147 of 192 United Nations Member States participated in UNGASS reporting in 2008 and 125 of them (85%) submitted data on blood safety. Ninety-one of the 125 countries (73%) reported that 100% of collected blood units were screened in a quality assured manner, but 34 countries did not screen all collected blood units in accordance with minimum quality standards. GDBS data showed that 80.7 million blood units were collected globally in 167 countries during 2004–2005, of which 77.3 million were tested for HIV and at least 0.6 million of the remaining 3.4 million donations went untested. In conclusion, progress has been made toward eliminating blood transfusion as a significant cause of HIV infection globally. Screening all donated blood for HIV in accordance with minimum quality standards remains vital, however, as health care systems should, at a minimum, do no harm. This goal is achievable and would assist in reaching Millennium Development Goals by 2015.

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Editors’ note: Because receiving HIV-infected blood leads to HIV infection in 95 to 100 per cent of people who are transfused with it, ensuring the safety of blood transfusion is a highly cost-effective prevention measure at an estimated 18$ per HIV infection averted. The fact that screening all donated blood in accordance with standardised procedures in a quality assured manner is still not universal around the world is disturbing. Gaps in blood supply in some settings are endangering lives and 50% of transfusions are unnecessary in others, but it is of immediate concern that so many countries are failing to ensure safe blood for their citizens when they are in dire need. Achieving this goal is not beyond reach and will save lives.  

Vamvakas EC. Scientific background on the risk engendered by reducing the lifetime blood donation deferral period for men who have sex with men. Transfus Med Rev. 2009 Apr;23(2):85-102.

The lifetime deferral for men who have sex with men has not been harmonized with the 12-month deferral for similar-risk activities through heterosexual contacts. This occurs primarily because of fears of increased transfusion transmission of known sexually and transfusion-transmitted viruses for which donor blood is (eg, HIV) or is not (eg, human herpesvirus 8 [HHV-8]) tested and also of fears of novel agents that may share the epidemiology and long asymptomatic phase of HIV. A 12-month men who have sex with men deferral could result in release of 1 HIV-infectious donation every 11 years in the United States. This risk is smaller than the risk from allowing the continued use of pooled whole blood-derived platelets (release of 1 infectious platelet dose every 1.67 years), a risk that is considered “tolerable.” Provided that measures to reduce the number of allogeneic-donor exposures to novel pathogens (which may be vector- or food-borne rather than sexually transmitted) are implemented, and the deferral for similar-risk activities through heterosexual contacts is extended to 5 years, a 5-year men who have sex with men deferral could be justified because of the interval between emergence of a novel pathogen and introduction of measures to protect the blood supply. Also, provided that measures to protect the blood supply from HHV-8 are implemented, a lifetime men who have sex with men deferral could be justified because of the uncertainty about the clinical consequences of transfusion transmission of HHV-8. Because such alternate measures, which would have had a greater impact on safety than the men who have sex with men deferral, have not been implemented to demonstrate a consistent approach to safety, maintenance of the current men who have sex with men deferral appears to be selectively precautionary and cannot be justified.

Editors’ note: Arguments have been advanced to harmonise the deferral periods for men who have sex with men with those for heterosexuals with similar-risk activities. Argentina, Brazil, Japan, Hungary, New Zealand, Russia, and South Africa have substituted a 1-, 5-, or 10-year deferral for the lifetime deferral of men who have sex with men. The USA, Canada, and the 19-nation European Blood Alliance maintain their current positions. This article argues cogently for a scientifically based, consistent approach to blood safety. It highlights the ramifications for blood safety of inconsistencies in national policies, arguing that the men who have sex with men lifetime deferral is selectively precautionary. More can be achieved by interventions to protect the blood supply against HHV-8 and by prohibiting the use of pooled whole blood-derived platelets. On balance, arguments can be made that extending the heterosexual deferral from 1 year to 5 years and harmonising the men who have sex with men deferral to 5 years would reasonably protect against an ‘HIV-like’ agent that could emerge in the future.

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.

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Volkow P, Brouwer KC, Loza O, Ramos R, Lozada R, Garfein RS, Magis-Rodriguez C, Firestone-Cruz M, Strathdee SA. Cross-border paid plasma donation among injection drug users in two Mexico-U.S. border cities. Int J Drug Policy. 2009 Feb 18. [Epub ahead of print]

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.

Moghimi M, Marashi SA, Kabir A, Taghipour HR, Faghihi-Kashani AH, Ghoddoosi I, Alavian SM. Knowledge, attitude, and practice of Iranian surgeons about blood-borne diseases. J Surg Res. 2008 Feb 1. [Epub ahead of print]

Perhaps more than any other healthcare worker, it is the surgeons who are at an increased risk of exposure to hepatitis B (HB) virus, hepatitis C virus, and human immunodeficiency virus. The aim of this study was to evaluate surgeons’ concerns regarding risk awareness and behavioral methods of protection against blood-borne pathogen transmission during surgery. A 31-item questionnaire with a reliability coefficient of 0.73 was used. Of 575 surgeons invited to participate from three universities and one national annual surgical society between May and July 2007, 430 (75%) returned completed forms. Concern about being infected with blood-borne diseases was more than 70 (from a total score of 100). Only 12.9% of surgeons always used double gloves. Complete vaccination against HB was done in about 76% of surgeons and only 56.8% had checked their HB surface antibody (anti-HBs) level. Older surgeons never used double gloves (P = 0.001). Iranian surgeons are not aware of the correct percentage of infected patients with and seroconversion rate of blood-borne diseases, do not use double gloves adequately, do not report their needlestick injuries, vaccinate against HB, and check anti-HBs after vaccination. Educational meetings, pamphlets, and facilities must be provided to health care workers, informing them of hazards, prevention, and postexposure prophylaxis to needlestick injuries, vaccination efficacy, and wearing double gloves.

Editors’ note: These middle-aged surgeons with relatively high surgical experience have not translated their concerns about the risk of blood-borne transmission into highly effective protection strategies. Double gloving, which increases protection by providing a second barrier, is more common among younger surgeons who need to encourage this practice as a surgical norm among their elders, along with masks and protective glasses.

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PLoS Medicine Editors. PLoS Med. 2008 Aug 26;5(8):e182. A crucial role for surgery in reaching the UN Millennium Development Goals. Recent efforts to bring surgery into the global health conversation have focused on arguments that surgical conditions should be considered as “neglected diseases” that disproportionately affect the world’s poorest people. There are at least five important reasons why providing surgery services should be considered a global public health priority. First, surgical conditions constitute a substantial global burden of disease, led by injuries, followed by malignancies, congenital anomalies, pregnancy complications, cataracts, and perinatal conditions. Second, surgery is a global public health issue because of global disparities in surgical care: 30% of the world’s population receives 73.6% of the estimated 234.2 million major surgical procedures performed worldwide each year, with the poorest third receiving only 3.5%. Third, surgery can be remarkably cost-effective when compared with some of the interventions that are considered the building blocks of global public health. Fourth, building surgical services, which requires infrastructure, supplies, and human resources, may in turn help to build health systems and to strengthen primary care. Finally, it is feasible to deliver surgical services even in the most resource-constrained settings. Surgery could play an essential role in meeting many of the 2015 United Nations Millennium Development Goals. For example, trauma care, obstetric surgery, and general surgical services are essential components in reaching goal 4 (reducing child mortality) and goal 5 (improving maternal health). Surgery can play a role in tackling infectious diseases (goal 6): male circumcision may reduce the risk of men acquiring HIV through heterosexual sex by 60%. With foresight and planning, the impending scale-up of male circumcision services in Africa could help to provide the infrastructure to build surgical services more generally. The authors argue that there is even a link between surgery and goal 1, the goal of halving the number of people living in poverty. A survey of patients at the Aravind Eye Hospital in Madurai, India found that 85% of men and 58% of women who had lost their jobs as a result of blindness from cataract regained those jobs after surgery. “Improving surgical capacity at district hospital level” was among the top 30 solutions at this year’s Copenhagen Consensus meeting of distinguished economists to the question of how best to advance global welfare, especially the welfare of the developing world. The authors conclude that surgery is beginning to outgrow its status as the “neglected stepchild of global public health”.

Editors’ notes: If this open-access article sensitises surgeons around the world to the potential that their skills can play in achieving human development goals and if the skills of those who are motivated, culturally sensitive, and willing to learn from their national counterparts can be channelled by locally led teams into effective and high quality surgical services for the underserved, then surgery will no longer be a ‘neglected disease’.

de Walque D. Do unsafe tetanus toxoid injections play a significant role in the transmission of HIV/AIDS? Evidence from seven African countries. Sex Transm Infect. 2008 ;84(2):122-5.

Although sexual transmission is generally considered to be the main factor driving the HIV epidemic in Africa, recent studies have claimed that iatrogenic transmission should be considered as an important source of HIV infection. In particular, receipt of tetanus toxoid injections during pregnancy has been reported to be associated with HIV infection in Kenya. The objective of this paper is to assess the robustness of this association among women in nationally representative HIV surveys in seven African countries. The association between prophylactic tetanus toxoid injections during pregnancy and HIV infection was analysed, using individual-level data from women who gave birth in the past five years. These data are from the nationally representative Demographic and Health Surveys, which included HIV testing in seven African countries: Burkina Faso 2003 (N = 2424), Cameroon 2004 (N = 2600), Ethiopia 2005 (N = 2886), Ghana 2003 (N = 2560), Kenya 2003 (N = 1617), Lesotho 2004 (N = 1278 ) and Senegal 2005 (N = 2126). Once the odds ratios (OR) were adjusted for five-year age groups and for ethnic, urban and regional indicators, the association between prophylactic tetanus toxoid injections during pregnancy and HIV infection was never statistically significant in any of the seven countries. Only in Cameroon was there an association between previous tetanus toxoid injection and HIV positivity but it became weaker (OR 1.53, 95% CI 0.91 to 2.57) once urban location and ethnic group were adjusted for. Although the risk of HIV infection through unsafe injections and healthcare should not be ignored and should be reduced, it does not seem that there is, at present and in the seven countries studied, strong evidence supporting the claim that unsafe tetanus toxoid injections are a major factor driving the HIV epidemic.

Editors’ note: After simple adjustment for age, location, and ethnicity in these Demographic and Health Survey datasets from seven countries, there were no correlations found between tetanus toxoid injections during pregnancy and HIV infection. Injection safety is important in healthcare settings in Africa, as it is everywhere, but it should not detract from concerted efforts to address the main mode of HIV transmission in these countries – sexual transmission.

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Thomson N, Sutcliffe CG, Sirirojn B, Sintupat K, Aramrattana A, Samuels A, Celentano DD. Penile Modification in Young Thai Men: Risk Environments, Procedures and Wide Spread Implications for HIV and Sexually Transmitted Infections. Sex Transm Infect. 2008 Jan 11.

Thomson and colleagues aimed to determine the prevalence and types of penile modification and describe the circumstances surrounding this practice among a sample of young methamphetamine users in Thailand. A mixed methods study was conducted in Chiang Mai, Thailand in 2005-6. One hundred young men were surveyed for the quantitative study and in-depth interviews were administered to 9 men, 11 women and 1 transgender. The prevalence of penile modification was 51%, with the most common type being inlaying with muk(s) (61%). The majority of modifications were performed in prison or juvenile detention (80%) by a friend (90%). Motivations for penile modification included peer pressure and perceived enhanced female sexual pleasure. In prison, the practice was veiled in secrecy, the conditions under which modification was performed were unhygienic, sometimes leading to infection, and sharing equipment was common. Men and women reported that condom use was more difficult post modification as condoms were more likely to break or leak and less likely to fit correctly. In addition, sexual intercourse was often painful for the female partner. In conclusion, penile modification is prevalent in this group of young methamphetamine users and is associated with behaviours and consequences that could facilitate the spread of HIV and other sexually transmitted infections.

Editors’ note: Penile modification practices in Thailand date back to the fourteenth century among the aristocracy but today are associated with prisons, the army, and the working class. Over half of one hundred consecutive male participants in a trial to reduce harms associated with methamphetamine use had penile modifications that had been performed in unhygienic settings. The risk of infection, including with blood borne pathogens transmitted through sharing of equipment at the time of the procedure, painful intercourse with trauma experienced by the receptive partner during intercourse, and condom breakage/leakage all raise concerns of increased risk for HIV acquisition and transmission.

Ansah JK, Acquaye J. Ten years of preoperative autologous blood donation in Accra. Ghana Med J 2006;40:142-7.

Pre-operative autologous blood donation (PABD) is utilized to circumvent the use of allogenic blood for various reasons. Ansah and Acquaye describe the distribution in terms of demographic characteristic, trends in participation and result of screening test of the PABD programme of the Accra Area Blood Center from 1993-2003. This is a retrospective descriptive study of PABD in patients scheduled for a variety of elective surgical procedures, in different levels of institutional health care in Accra, Ghana. Data from existing records of patients who had participated in PABD were collated and analyzed. The results showed that five hundred and forty six (546) females and 89 males participated, with ages ranging between 14-74 years. Majority of the patients (76.7%) underwent gynaecological surgery. A total of 330 (52%) donated one unit only, and 299 (47.1%) donated two units. Majority of the patients (56.4%) had the surgery at the Korle-Bu Teaching Hospital. Of the donations, 21 (3.3%), 1 (0.2%), 1 (0.3%) and nil were positive for HBV, HIV I & II, HCV and VDRL respectively. A total of 848 (89.4%) autologous cross-matched units were issued out. There was a steady progressive increase in participation. In conclusion, mainly adult females scheduled for gynaecological surgeries in Korle-Bu Teaching Hospital participated, while almost equal proportions donated one or two units of blood which meets the blood needs of most elective surgeries. Therefore healthy patients going for elective surgeries in regions with limited blood supply must be encouraged to enter a Pre-operative autologous blood donation Programme. Further studies in this field should evaluate motivational factors for participation.

Editors’ note: Autologous blood transfusion, storing your own blood ahead of time in case you will need it for an elective surgical procedure, has obvious advantages for the individual but is controversial in many settings because of its potential to undermine emergency blood services if it draws resources away from them.

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Stramer SL. Current risks of transfusion-transmitted agents: a review. Arch Pathol Lab Med 2007;131:702-7.

Infectious disease testing has dramatically improved the safety of blood for transfusion in the United States, especially since the introduction in 1999 of nucleic acid amplification testing. In 2004, methods (primarily culturing) for detecting bacteria in platelets were also added. Stramer’s objective is to provide current risk estimates for the likelihood of viral transmission by test-negative blood components and to illustrate the safety improvements since the introduction of bacterial testing of platelets. The author’s data sources are published literature from 1999 through 2006 and unpublished American Red Cross data sources. The author concludes that the risk of human immunodeficiency virus and hepatitis C virus transmission through blood transfusion since the introduction of nucleic acid amplification testing is approximately 1 in 2 million. Hepatitis B virus risk, for which nucleic acid amplification testing is not performed routinely, remains at 1 in 200,000 to 500,000 using a combination of anti-hepatitis B core and hepatitis B surface antigen testing. Seven cases of transfusion-transmitted West Nile virus have been reported since the introduction of nucleic acid amplification testing in 2003, but none has been reported since system-wide implementation of processes to increase the test sensitivity for use in epidemic areas. The residual risk of receiving a bacterially contaminated platelet component with clinical consequences is estimated at approximately 1 in 75,000, if culture negative and 1 in 33,000 if not tested by culture methods.

Editors’ note: The risks of acquiring transfusion-associated infectious agents have dropped significantly in the USA and other countries with the resources to devote to assuring the safety of the blood supply. However, primary prevention starts by preventing accidents in the workplace, on the highway and elsewhere, as well as by reducing the prescribing of blood transfusion in hospitals unless absolutely necessary.

O’brien SF, Yi QL, Fan W, Scalia V, Kleinman SH, Vamvakas EC. Current incidence and estimated residual risk of transfusion-transmitted infections in donations made to Canadian Blood Services. Transfusion 2007;47:316-25.

New testing methods such as nucleic acid amplification testing (NAT) and chemiluminescent serologic assays have been introduced, more precise estimates for infectious window periods are available, and a new method for estimating the residual risk (RR) of transfusion-transmitted infections (TTIs) has been developed. Thus, O’Brien and colleagues note that available RR estimates for Canada need to be updated. Incidence rates for known TTI markers were determined for all allogeneic whole-blood donations made to Canadian Blood Services between 2001 and 2005; they were derived from NAT conversions or seroconversions of repeat donors with at least two donations in a 3-year period. RR estimates for human immunodeficiency virus (HIV)-1 and hepatitis C virus (HCV) derived from the classical incidence/window-period model were compared to those obtained by the new method that estimates incidence from NAT-positive, antibody-negative donations (NAT-yield cases) from all donors divided by person-years. With the classical method, the RR of HIV (1 per 7.8 million donations) and HCV (1 per 2.3 million) were low; HBV RR was higher (1 per 153,000). HCV RR was significantly lower when estimated with the new method (1 per 13 million). Eleven HCV NAT-yield cases were predicted by applying the classical method to our seroconversion data but only 2 were observed (p = 0.011). Observed HIV-1 NAT-yield cases (n = 1) matched those predicted (n = 0.7). The authors conclude that new tests have reduced an already low risk of TTI in Canada. HCV RR estimates by two different methods differed but both were low.

Editors’ note: Nucleic acid amplification and chemiluminescent testing which can pick up the window period while antibody tests are still negative have virtually eliminated transfusion-transmitted HIV and hepatitis C infection through blood banks in Canada.