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.

Fritts M, Crawford CC, Quibell D, Gupta A, Jonas WB, Coulter ID, Andrade A. Traditional Indian medicine and homeopathy for HIV/AIDS: a review of the literature. AIDS Res Ther. 2008;5(1):25.

India ranks third in the world in absolute burden of HIV. While increasing numbers of Government-sponsored clinics are providing free antiretroviral therapy, its utility is limited by lack of affordability and acceptability and the requirement for lifelong administration. Allopathic practitioners in India are outnumbered by practitioners of traditional Indian medicine and homeopathy, which is used by two-thirds of its population in rural areas to help meet its primary health care needs. However, little is known about traditional Indian medicine and homeopathy use, safety or efficacy in HIV management. These data suggest that India’s community-based, culturally-relevant traditional Indian medicine and homeopathy system, which is one of the largest indigenous medical systems in the world, remains an untapped ally in the fight against its HIV epidemic. The purpose of this review was to assess the quality of peer-reviewed, published literature on traditional Indian medicine and homeopathy for HIV treatment and care. Of 160 original articles reviewed, 19 laboratory studies, 17 clinical studies and six previous reviews of the literature were identified that covered at least one system of traditional Indian medicine and homeopathy, which includes Ayurveda, yoga, naturopathy, Unani medicine, and Siddha medicine and homeopathy. Most studies examined either Ayurvedic or homeopathic treatments. Only four of these studies were randomized controlled trials, and only 10 were published in MEDLINE-indexed journals. Overall, the studies reported positive effects and even cure and reversal of HIV infection, but frequent design flaws call into question their internal and external validity. Common reasons for poor methodological quality included lack of details on products and their standardization, small sample sizes, selection of inappropriate or weak outcome measures, and incomplete reporting of study results. This review exposes a broad gap between the widespread use of traditional Indian medicine and homeopathy therapies for HIV, and the dearth of high-quality data supporting their effectiveness and safety. In light of the suboptimal effectiveness of vaccines, antiretroviral treatment, barrier methods, and behaviour change strategies for prevention and cure of HIV infection, it is both important and urgent to develop a rigorous research agenda that uses innovative methodologies to investigate, evaluate, and maximize the role of traditional Indian medicine and homeopathy in managing HIV and associated illnesses in India.

Editors' note: This review presents an interesting overview of the history and principles of each system of traditional Indian medicine and homeopathy and highlights the current antiretroviral treatment gap, before summarising the results of in vitro, in vivo, and clinical studies of the impact of traditional Indian medicine and homeopathy on HIV. While yoga and healthy diet are considered beneficial by most people, the use of herbal preparations and homeopathic treatments for tuberculosis and HIV in the absence of data on effectiveness is concerning. Both the paucity of evidence and the use of these therapies by significant numbers of people living with HIV call for systematic assessment of the potential benefits and potential harms of traditional Indian medicine and homeopathy. Increased cross-training between traditional medicine and allopathic (modern) practitioners and development of a collaborative research agenda for studies using rigorous methodologies hold the promise of improved patient outcomes.

Tonwe-Gold and colleagues describe a family-focused approach to HIV care and treatment and report on the first 2 years experience of implementing the mother-to-child transmission (MTCT)-plus program in Abidjan, Côte d’Ivoire. The MTCT-plus initiative aims to enrol HIV-infected pregnant and postpartum women in comprehensive HIV care and treatment for themselves and their families. Between August 2003 and August 2005, 605 HIV-infected pregnant or postpartum women and 582 HIV-exposed infants enrolled. Of their 568 male partners reported alive, 52% were aware of their wife’s HIV status and 30% were tested for HIV; 53% of these tested partners were found to be HIV-infected and 78% enrolled into the program. Overall only 10% of the women enrolled together with their infected partner. On the other hand, the program involved half of the seronegative men who came for voluntary counselling and testing in the care of their families. Of 1624 children <15 years reported alive by their mothers (excluding the last newborn infants of the most recent pregnancy systematically screened for HIV), only 10.8% were brought in for HIV testing, of whom 12.3% were found to be HIV-infected. With respect to lessons learned and challenges, the authors conclude that this family-focused model of HIV care pays attention to the needs of families and household members. The program was successful in enrolling HIV women, their partners and infants in continuous follow-up. However engaging partners and family members of newly enrolled women into care involves numerous challenges such as disclosure of HIV status by women to their partners and family members. Further efforts are required to understand barriers for families accessing HIV services as strategies to improve partner involvement and provide access to care for other children in the households are needed in this West African urban setting.

Editors' note: Nondisclosure was the major factor limiting this family-centred programme in two poor urban Abidjan slums experiencing multiple unfavourable social and political conditions. The cascade of effort deployed to engage partners resulted in 30% having HIV testing and counselling, however only 69 of the estimated 300 men likely to have HIV infection enrolled in the programme. Testing was also an entry point for seronegative men to participate in adherence support sessions for their family members and attend peer support groups. Recognizing that the immediate environment has a direct impact on an individual’s ability to promote his or her own health, the innovative MTCT-plus model of care starts with pregnant women as the entry point to HIV care and services for the whole family.

Mbikusita-Lewanika M, Stephen H, Thomas J. The prevalence of the use of ‘dry sex’ traditional medicines, among Zambian women, and the profile of the users. Psychol Health Med. 2009;14(2):227-38.

Concern has been voiced about the ‘dry sex’ practice in Southern and Central Africa, and its possible role in HIV transmission. Despite this concern, there has been little information about the practice. Most of the available information has been anecdotal, speculative or inadequate mainly because of cultural reluctance to discuss or investigate personal sexual issues. This article provides information about the prevalence of the practice in Zambia and the profile of its practitioners. A cross-sectional study involving 812 Zambian women was undertaken in Lusaka , the capital city of Zambia. Quantitative and qualitative data was obtained through self-administered questionnaires, interviews, in-depth interviews and focus group discussions. The quantitative data were analysed using SPSS, and the qualitative data were used to complement and clarify the quantitative data. Awareness of the ‘dry sex’ practice was almost universal among Zambian women. About two-thirds had used ‘dry sex’ traditional medicines at some point in their lives, and about half were using them. Those who were most likely to have been using, or to have used ‘dry sex’ traditional medicines, were those who were older, married, with little or no formal education, mainstream Christians, from the lower socio-economic levels, homemakers, manual workers (p < 0.001), originally from the Eastern province of Zambia (p < 0.002) and those who had spent most of their formative years in rural areas (p < 0.006).The study showed that the knowledge and use of ‘dry sex’ traditional medicines is widespread among Zambian women, especially among those who were most likely to adhere to traditional views and beliefs about womanhood and marriage, and perhaps those likely to have a poor sense of self-worth or less confidence. In view of the concern about the possible role of ‘dry sex’ in HIV transmission, these findings would be useful in health education strategies.

Editors' note: This study of ‘dry sex practices’ or the use of traditional medicines to constrict the vagina or increase body heat, found significant associations with a number of factors but unfortunately the methodology and results of a regression analysis to tease out their interrelationships and identify confounding factors are not presented. However, an important finding was that only 7% of women who practised dry sex did so in anticipation of sexual activity, 16% used the medicines when they felt their bodies needed it, and 76% said they used them regularly anyway. Although qualitative data suggests that this may be related to concepts of womanhood, the possibility cannot be ignored that a vicious circle of chronic inflammation and resultant vaginal discharge induced by this practice may create the motivation for continuing self-medication.

Vaginal practices, such as intra-vaginal cleansing, drying and tightening, are suspected of placing women at higher risk of acquiring HIV and sexually transmitted infections. Yet, there is limited understanding of what these practices entail, what motivates women to undertake them and what their socio-cultural and historical meanings are. This paper explores the range of vaginal practices used by women in KwaZulu-Natal, South Africa and locates these within the context of local patterns of migration and understandings of sexual health and pleasure. Study activities took place at an urban and rural site employing qualitative research techniques: semi-structured interviewing and an additional ethnographic component in the rural site. Vaginal practices were believed to be ubiquitous and a wide range of substances and procedures were described. Strong motivations for vaginal practices included women’s desire to enhance men’s sexual pleasure, ensure men’s fidelity and exercise agency and control in their relationships. The common use of traditional medicines in this quest to maintain stable relationships and affect the course of love, suggests a complexity that cannot be captured by simple terms like ‘dry sex’. Scorgie and colleagues argue instead that any interventions to change women’s reliance on vaginal practices must recognise and attend to the broader social contexts in which they are embedded.

Editors' note: This detailed qualitative study reveals a complex array of motives for potentially harmful vaginal practices among women in Kwa Zulu Natal, a province with very high HIV incidence and prevalence among women. Products used include traditional medicines and a wide range of commercial preparations while procedures include cleansing, topical application, insertion, making incisions, and ingestion. Multiple, concurrent sexual partnerships in a context of poverty, labour migration, and unemployment set the stage for women’s mutual suspicion, jealousy, and competition over men as sources of income. Promoting notions of vaginal health to change these practices in order to reduce HIV risk will require that local women’s groups, advocates, and peer education initiatives address the socioeconomic and gender dynamics that underpin them.

Zou J, Yamanaka Y, John M, Watt M, Ostermann J, Thielman N. Religion and HIV in Tanzania: influence of religious beliefs on HIV stigma, disclosure, and treatment attitudes. BMC Public Health. 2009;9(1):75.

Religion shapes everyday beliefs and activities, but few studies have examined its associations with attitudes about HIV. This exploratory study in Tanzania probed associations between religious beliefs and HIV stigma, disclosure, and attitudes toward antiretroviral treatment. A self-administered survey was distributed to a convenience sample of parishioners (n=438) attending Catholic, Lutheran, and Pentecostal churches in both urban and rural areas. The survey included questions about religious beliefs, opinions about HIV, and knowledge and attitudes about antiretroviral treatment. Multivariate logistic regression analysis was performed to assess how religion was associated with perceptions about HIV, HIV treatment, and people living with HIV. Results indicate that shame-related HIV stigma is strongly associated with religious beliefs such as the belief that HIV is a punishment from God (p<0.01) or that people living with HIV have not followed the Word of God (p<0.001). Most participants (84.2%) said that they would disclose their HIV status to their pastor or congregation if they became infected. Although the majority of respondents (80.8%) believed that prayer could cure HIV, almost all (93.7%) said that they would begin antiretroviral treatment if they became HIV-infected. The multivariate analysis found that respondents’ hypothetical willingness to begin antiretroviral treatment was not significantly associated with the belief that prayer could cure HIV or with other religious factors. Refusal of antiretroviral treatment was instead correlated with lack of secondary schooling and lack of knowledge about antiretroviral treatment. The decision to start antiretroviral treatment hinged primarily on education-level and knowledge about antiretroviral treatment rather than on religious factors. Research results highlight the influence of religious beliefs on HIV-related stigma and willingness to disclose, and should help to inform HIV-education outreach for religious groups.

Editors' note: Christians make up about 30% of the population in Tanzania, with churches being influential social networks with the power to support or stigmatize people living with HIV, promote or impede HIV education, and endorse or reject HIV medical treatment. Only 42.7% of respondents had been tested for HIV and, interestingly, Catholics were least likely (42.7%) and Pentecostals were most likely (69.7%) to report never having used condoms. Despite the study’s limitations, including data collection in the presence of pastors after church services, the findings are relevant for the design of outreach campaigns and theological discussions in faith-based communities to reduce shame-related stigma, enhance disclosure, and contribute to improved social support for people living with HIV.