Blood Safety and HIV

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 syringes,¹ 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.

back to top 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 high and low-income 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 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.⁹ 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.¹⁰

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.¹¹ 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.¹² However, despite more lower-income countries implementing these strategies and guidelines since 2004, HIV infection continues to be a risk associated with blood transfusions in many parts of the world. The percentage of donated blood which is screened in a quality-assured manner currently stands at 99.7 for high-income countries, 83.6 for middle-income countries and 53.4 for low-income countries.¹³

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 28.72.¹⁴ These donors are sought after because they are more likely to be donating for altruistic reasons rather than for any personal gain.¹⁵ 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, high-risk individuals that would otherwise not donate, may do so 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 percentage of blood donations.¹⁶ For example, 70 percent of donations in Pakistan are from 'family and replacement' donors with a further 10 percent of donations from paid donors.¹⁷ 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.¹⁸

The process of screening donors involves asking a series of questions about the donors' lifestyle to ensure individuals who may be infected with HIV do not donate blood. By evaluating whether a blood donor participates in risky behaviour, the risk of them unknowingly donating HIV-infected blood can be determined.^{19 20}

The most recent reported case in the US of HIV being transmitted through transfusion occurred in 2008.²¹ 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.²²

The debate: Men who have sex with men (MSM) donating blood

Most countries have replaced the ban on MSM from donating blood with a deferral period, ranging from a number of months to years. Whilst most countries enforced a ban on MSM from donating in the years when HIV was first reported, as scientific knowledge about HIV has increased and blood screening processes have been developed most countries now consider it safe for MSM to donate blood under certain conditions. However, the ban on MSM is still enforced in a few countries, such as Northern Ireland 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. It 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.²³

"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.^{24 25 26 27 28} Organisations such as the American Red Cross support a deferral rather than a lifetime ban for MSM.²⁹ 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.³⁰ 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.³¹

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.^{32 33} 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.³⁴

Following a review in June 2010 the U.S. 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.³⁵ Nevertheless, in 2011, following an evidence-based review the UK government decided to lift the lifetime ban on men-who-have-sex-with-men (MSM) donating blood.^{36 37} However, MSM remain banned for a year following their last sexual (anal or oral) encounter, protected or unprotected.³⁸ In 2013, Canada also removed its lifetime ban, replacing it with a 5 year deferral period.³⁹ Despite this positive move, many argue that the five year deferral period is still discriminatory.⁴⁰

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.⁴¹ 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.⁴²

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.⁴³

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.⁴⁴ 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.⁴⁵ 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.^{46 47}

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.^{48 49} The WHO asserts this is reliant on the formulation and implementation of a national blood policy by a country's government.⁵⁰

Do all countries test for HIV?

Each year, 92 million units of blood are donated, half in high-income and half in low- and middle-income countries.⁵¹ Latest figures show that 39 countries lack the resources to screen for transfusion-transmissible infections (TTIs).⁵² UNAIDS figures show only half of Pakistan's annual 1.5 million bags of transfused blood are screened⁵³ and it is believed that 19 percent of new HIV infections in Pakistan are due to unsafe blood.^{54 55} Worryingly it is often countries with a high HIV prevalence that have inadequate screening programmes in place. For example, although the AIDS epidemic in Tanzania is generalised (HIV prevalence is 6 percent), blood screening is extremely limited.⁵⁶ Between 2009 and 2010, only 33.7 percent of donated blood units were screened for HIV and other TTIs.

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.⁵⁷ 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.^{58 59} 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.Today, HIV screening had markedly improved, with the introduction of advanced screening techniques in some testing facilities. As of 2011, 6.6 percent of people living with HIV in China were former blood donors or transfusion recipients.⁶⁰

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.^{61 62} 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.⁶³

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.^{64 65} 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.^{66 67}

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.⁶⁸ 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'.^{69 70} 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.^{71 72} A lack of safe blood in southern Africa accounts for an estimated 15 percent of anemia related child deaths^{73 74} and 44 percent of maternal deaths are due to hemorrhaging during pregnancy in sub-Saharan Africa.^{75 76}

A country needs a blood donation rate of 10 units per 1000 population per year. Currently low-income countries only receive 2.8 units, increasing the pressure on countries to source blood supplies unsafely.⁷⁷ 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)⁷⁸ will not be achieved without persistent efforts by individual countries and the global community to develop safe and sustainable blood supplies.

back to top 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"⁷⁹

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 body⁸⁰ and it has been found that syringes containing HIV infected blood can still transmit HIV, even after being rinsed, for up to 4 weeks.⁸¹ Studies have illustrated the parallel between the re-use of equipment and infection with blood borne viruses.^{82 83}

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.⁸⁴ Gross re-use of medical equipment, including syringes, was reported in three of Kazakhstan's Hospitals in 2007.⁸⁵ 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 1991.⁸⁶

Health systems must be strengthened to provide healthcare workers with training and resources if injections are to be made safer.^{87 88} 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.⁸⁹ 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.^{90 91 92 93 94 95} However, WHO estimates for sub-Saharan Africa are far more conservative at 2.5 percent.^{96 97} They uphold that although HIV transmission in healthcare settings, notably medical injections, is an area of concern, most infections are sexually transmitted.⁹⁸

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.⁹⁹

The Safe Injection Global Network (SIGN)¹⁰⁰ 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.¹⁰¹ 'Making Medical Injections Safer' (MMIS)¹⁰² , 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.¹⁰³ 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.¹⁰⁴

Technology such as single dose, pre-filled Auto-Disable (AD) injection devices (used for vaccinations) and AD syringes¹⁰⁵ , which have a one-way valve making the syringe useless after one use, have the potential to make injections in developing countries safer.^{106 107 108} 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.¹⁰⁹ However, vaccinations only account for 10 percent of injections whereas 90 percent are for curative (or treatment) purposes.¹¹⁰

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.¹¹¹ Despite the phasing out of sterilizable and disposable syringes by some international organizations and governments, both continue to be used instead of AD syringes.¹¹² 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.¹¹³ 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.

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".¹¹⁴ 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).^{115 116} UNICEF mass vaccination campaigns can vaccinate an estimated 10 million children in one week and they use only AD syringes.¹¹⁷

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, an Ambulatory Surgical Center (ASC) 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.^{118 119} This resulted in 40,000 people requiring tests for HIV, hepatitis C and B.¹²⁰ Following this, an inspection by the Nevada Board of Licensure and Certification found lapses of infection control in 28 of the states 51 ASCs.¹²¹ 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.¹²² Nevertheless, it is evident that lapses of infection control continue to occur. Following further inspections of ASCs in 3 US states, by the Centre for Medicare and Medicaid Services, lapses of infection control during injection practices and medication handling were reported in 28 percent of ASCs; notably the re-use of single-dose medication vials for more than one patient.¹²³

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.¹²⁴ 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.¹²⁵

WHO estimates that up to 70 percent of injections in some countries, were 'medically unnecessary'.^{126 127} For example, in some countries injections are given unnecessarily to administer antibiotics or vitamins.^{128 129} 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.

back to top 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.¹³⁰

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 1000.¹³¹ 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.¹³²

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.¹³³

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.¹³⁴

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 1999.¹³⁵

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.¹³⁶ 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 Organization¹³⁷ 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.¹³⁸ 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.¹³⁹

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.

back to top Medical waste and HIV

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 in 60, out of 68 establishments surveyed, 22.6 percent of the daily waste was hazardous.¹⁴⁰ 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.¹⁴¹ 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.¹⁴²

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.

back to top Conclusion

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.^{143 144}

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.

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References back to top

1. UNICEF 'Immunization: Injection safety'
2. WHO (2006, 27th June) 'Making Safe Blood Available in Africa'
3. All Africa (2009, 30th December) 'Africa: HIV Transmission Via Transfusions in Continent Remains High'
4. All Africa (2009, 30th December) 'Africa: HIV Transmission Via Transfusions in Continent Remains High'
5. NHS 'Will I need a blood transfusion?'
6. Franceschi, S et al. (1995, 9th December) 'Trends in incidence of AIDS associated with transfusion of blood and blood products in Europe and the United States, 1985-93' BMJ 311(7019)
7. World Federation of Hemophilia 'What are clotting factor deficiencies?'
8. World Federation of Hemophilia 'What are clotting factor deficiencies?'
9. Yorkshire Post (2011) ''Tainted blood' victims to get £130m of aid'
10. BBC News (1999, 8th April) 'Blood: The risks of infection'
11. WHO (2010) 'Screening Donated Blood for Transfusion-Transmissible Infections'
12. WHO (2010) 'Screening Donated Blood for Transfusion-Transmissible Infections'
13. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
14. WHO (2010) 'Voluntary blood donation'
15. WHO (2009, November) 'Global blood safety and availability'
16. WHO/UNAIDS/UNICEF (2010), 'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'
17. Pakistan Red Crescent Society 'Blood services'
18. UNGASS (2010) 'Country progress report: Pakistan 2010'
19. WHO (2010) 'Screening Donated Blood for Transfusion-Transmissible Infections'
20. NHS (2010, 19th May) 'Why we ask men who have sex with men not to give blood'
21. CDC (2010, 22nd October) 'HIV Transmission Through Transfusion - Missouri and Colorado, 2008' MMWR 59(41)
22. CDC (2010, 22nd October) 'HIV Transmission Through Transfusion - Missouri and Colorado, 2008' MMWR 59(41)
23. American Red Cross 'Eligibility Criteria by Alphabetical Listing'
24. The Independent (2010, 6th June) "My blood is 'gay' is that okay?"
25. Human Rights Campaign (2006, 14th March) 'Blood Donation Rules Should be Based on Science, Not Prejudice'
26. John Kerry (2010, 10th June) 'Kerry Fights To End Ban On Gay Men Donating Blood'
27. GMHC (2010) 'A Drive for Change: Reforming U.S. Blood Donation Policies'
28. Human Rights Campaign (2010, 6th November) 'HHS Advisory Committee Recommends Against Changing Gay and Bisexual Blood Ban'
29. CNN (2010, 26th May) 'Federal ban on gay men's blood donation to be reconsidered'
30. Human Rights Campaign 'FAQs: Blood donations'
31. Sam Gulube et al (2008, May) 'The importance of safe blood transfusions cannot be overemphasised' CME: Your SA Journal of CPD
32. CDC (2010, 10th March) 'Press release: CDC Analysis Provides New Look at Disproportionate Impact of HIV and Syphilis Among U.S. Gay and Bisexual Men'
33. FDA 'Blood Donations from Men Who Have Sex with Other Men Questions and Answers'
34. Washington Times (2010, 10th June) 'Decision nears on blood donor policy for gays'
35. Human Rights Campaign (2010, 6th November) 'HHS Advisory Committee Recommends Against Changing Gay and Bisexual Blood Ban'
36. UK Department of Health (2011, September) 'Lifetime blood donation ban lifted for men who have had sex with men'
37. Grenfell P. et al (2011, 8th September) 'Views and experiences of men who have sex with men on the ban on blood donation' ,BMJ 343
38. BBC News (2011, September) 'Gay men blood donor ban to be lifted'
39. Huffington Post (2013, May 22nd) 'Canada lifts blood donation ban on gay men'
40. National Post (Canada) (2013) 'Canada lifts lifetime ban on gay men giving blood, but they can only donate if celibate for five years'
41. WHO (2009, 16th-17th July) 'Technical Working Group on HIV Incidence Assays: Meeting Report'
42. WHO (2010) 'Screening Donated Blood for Transfusion-Transmissible Infections'
43. Gulube, S et.al (2008, May) 'The importance of safe blood transfusion cannot be overemphasised', CME: Your SA journal of CPD
44. WHO (2010) 'Screening Donated Blood for Transfusion-Transmissible Infections'
45. UNGASS (2010) 'Country progress report: Ghana 2010'
46. International Haemovigilance Network 'South Africa'
47. Sam Gulube et al (2008, May) 'The importance of safe blood transfusions cannot be overemphasised' CME: Your SA Journal of CPD
48. WHO (2010) 'Screening Donated Blood for Transfusion-Transmissible Infections'
49. WHO (2009, April) 'Priority interventions HIV/AIDS prevention, treatment and care in the health sector'
50. WHO 'National blood transfusion service'
51. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
52. WHO (2011) 'Global database on blood safety: Summary report 2011'
53. UNGASS (2010) 'Country progress report: Pakistan 2010'
54. Pakistan Red Crescent Society 'HIV Workplace Policy 2010-15'
55. IRIN (2008, 13th March) 'Pakistan: Unsafe blood transfusions pose HIV, hepatitis risk'
56. The United Republic of Tanzania (2012) 'Country Progress Reporting'
57. Shan, H et. al (2002) 'Blood banking in China' The Lancet 360(9347)
58. Reuters (2007, 6th September) 'China's blood still unsafe, needs help - report'
59. China Daily (2010, 20th January) '80 infected with AIDS in blood transfusions'
60. Ministry of Health of the People’s Republic of China (2012) '2012 China AIDS Response Progress Report'
61. WHO (2009, 30th September) 'Priority interventions HIV/AIDS prevention, treatment and care in the health sector'
62. Media Global (2010, 18th July) 'Killer blood transfusions targeted in the fight against HIV'
63. WHO (2007) 'Global Blood Safety and Availability'
64. WHO/UNAIDS/UNICEF (2010), 'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'
65. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
66. Teiji Takei, MD (2009, 1st December) 'Progress in Global Blood Safety for HIV', J Acquir Immune Deï¬c Syndr 52(2)
67. WHO (2009, June) 'Global Consultation: 100% Voluntary Non-Remunerated Donation of Blood and Blood Components'
68. Shan H et. al (2002) 'Blood banking in China' The Lancet 360(9347)
69. Shan H et. al (2002) 'Blood banking in China' The Lancet 360(9347)
70. Umeora O U et. al (2005, December) 'Socio-cultural barriers to voluntary blood donation for obstetric use in a rural Nigerian village', Afr J Reprod Health 9(3)
71. Medical News Today (2009, 17th November) 'Need To Address Hemophilia In Developing World Highlighted By Research'
72. National Heart Lung and Blood Institute 'Hemophilia'
73. WHO (2009) 'Fact file on blood transfusion'
74. English M et. al (2002, 9th February) 'Blood transfusion for severe anaemia in children in a Kenyan hospital' The Lancet 359(9305)
75. WHO (2008) 'Universal Access to Safe Blood Transfusion'
76. The Lancet (2007, 4th August) 'Improving blood safety worldwide'
77. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
78. End Poverty 2015 Millenium Campaign 'Resources'
79. WHO (2009) 'Annual Meeting of the Safe Injection Global Network: Injection Safety In Light Of Primary Health Care Reforms', World Health Organization Headquarters, Geneva Switzerland
80. Reid, S (2009) 'Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review', Harm Reduction Journal 6(24)
81. Abdala N et al. (1999) 'Survival of HIV-1 in syringes', Journal of Acquired Immune Deficiency Syndromes' 20(1)
82. WHO (2009) 'Annual Meeting of the Safe Injection Global Network: Injection Safety In Light Of Primary Health Care Reforms', World Health Organization Headquarters, Geneva Switzerland
83. Luby S P, et. al (1997, December) 'The relationship between therapeutic injections and high prevalence of hepatitis C infection in Hafizabad, Pakistan' Epidemiol Infect 119(3)
84. Irin/Plus News (2010, 9th July) 'South Africa: Counsellors to give "the prick"'
85. Medical News Today (2007, 20th September) 'HIV Outbreaks Linked To Blood Transfusions Discovered In Central Asia Since Kazakh Doctors Were Convicted Of Criminal Negligence'
86. Human Rights Watch (2006, August), 'Life Doesn't Wait - Romania's Failure to Protect and Support Children and Youth Living with HIV'
87. WHO (2009) 'Annual Meeting of the Safe Injection Global Network: Injection Safety In Light Of Primary Health Care Reforms', World Health Organization Headquarters, Geneva Switzerland
88. WHO (2010, March) 'Best practices for injections and related procedures toolkit'
89. Reid, S (2009) 'Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review', Harm Reduction Journal 6:24
90. Reid, S (2009) 'Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review', Harm Reduction Journal 6:24
91. The Lancet (2004, 7th February) 'Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections', 363(9407)
92. Gisselquist D, et. al (2002, October) 'HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission' Int J STD AIDS 13(10)
93. Gisselquist D, et. al (2004, February) 'HIV transmission during paediatric health care in sub-Saharan Africa--risks and evidence' S Afr Med J 94(2)
94. Reid S (2009, December) 'Non-vertical HIV transmission to children in sub-Saharan Africa' Int J STD AIDS 20(12)
95. Reid, S (2009) 'Increase in clinical prevalence of AIDS implies increase in unsafe medical injections', Int J STD AIDS 20(5)
96. UNAIDS (2009, December) '2009 AIDS epidemic update'
97. WHO (2003, 14th March) 'Expert group stresses that unsafe sex is primary mode of transmission of HIV in Africa'
98. WHO meeting (2003, 14th March) 'Unsafe Injection Practices and HIV Infection'
99. WHO (2009, April) 'Priority interventions: HIV/AIDS prevention, treatment and care in the health sector'
100. WHO 'The SIGN alliance'
101. All Africa (2010, 7th July) 'Kenya health personnel lined up for blood collection training'
102. MMIS 'Overview'
103. MMIS 'Training & Capacity Building'
104. MMIS 'Tanzania'
105. UNICEF (2010, 5th July) 'Vaccine Safety'
106. PATH (2009, December) 'An Overview of PATH's Injection Safety Work: 1999-2009'
107. WHO 'Safe syringes for injection safety'
108. UNICEF (2009, 18th August) 'Immunization'
109. WHO/UNICEF/UNFPA 2003 'Safety of injections: WHO-UNICEF-UNFPA joint statement on the use of auto-disable syringes in immunization services'
110. UNICEF (2010) 'Immunization: Injection Safety'
111. Business Standard (2010, 20th February) 'Gujarat's govt hospitals yet to use AD syringes, says HMD'
112. UNICEF 'Vaccine Safety'
113. WHO 'Immunization safety'
114. Washington Post (2005, 9th February) 'India's vaccines come with risk'
115. Dr Hoekstra, E 'UNICEF expert opinion: Injection Safety'
116. UNICEF 'Vaccine safety'
117. Dr Hoekstra, E 'UNICEF expert opinion: Injection Safety'
118. The Injury Board: National Newsdesk (2008) 'Reusing Syringes "Common Practice" at Las Vegas Clinics'
119. BBC News ( 2005, 17th June) 'Boy's needle cut sparks HIV scare'
120. The Injury Board: National Newsdesk (2008) 'Reusing Syringes "Common Practice" at Las Vegas Clinics'
121. Schaefer, M K. et al (2010) 'Infection Control Assessment of Ambulatory Surgical Centres' JAMA 303(22)
122. Safe Injection Practices Coalition (accessed 2012) One and Only Campaign
123. Schaefer, M K. et al (2010) 'Infection Control Assessment of Ambulatory Surgical Centres' JAMA 303(22)
124. Mishra, V et. al (2008, October) 'Medical injection use and HIV in sub-saharan Africa', USAID DHS Comparative reports 21
125. UNAIDS (2009, December) '2009 AIDS epidemic update'
126. WHO (2010, March) 'Best practices for injections and related procedures toolkit'
127. Anja M Hauri et al. (2004) 'The global burden of disease attributable to contaminated injections given in health care settings', Int J STD AIDS 15(1)
128. WHO 'Injection safety'
129. Simonsen L, et. al (1999) 'In Focus: Unsafe injections in the developing world and transmission of bloodborne pathogens: a review' Bulletin of WHO 77(10)
130. WHO (2010) 'HIV/AIDS in the workplace'
131. The Department of Health (September 2008) 'HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officer's Expert Advisory Group on AIDS, 2nd edition'
132. CDC (2003, July) 'Exposure to blood: What healthcare workers need to know'
133. CDC (2006, December) 'Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December 2006' (modified 10th September 2007)
134. CDC (2006, December) 'Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December 2006' (modified 10th September 2007)
135. Health Protection Agency (2008) 'Eye of the needle'.
136. CDC (2011, February) 'Occupational HIV transmission and prevention among health care workers'
137. WHO (December 2003) 'Aide-Memoire on health care worker safety'
138. WHO(2009) 'Annual Meeting of the Safe Injection Global Network: Injection Safety In Light Of Primary Health Care Reforms', World Health Organization Headquarters, Geneva Switzerland
139. The Department of Health (September 2008) 'HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officer's Expert Advisory Group on AIDS, 2nd edition'
140. Hassan M et al. (2008) 'Pattern of medical waste management: existing scenario in Dhaka City, Bangladesh', BMC Public Health 8:36
141. All Africa (2010, 23rd February) 'Nigeria: Unsafe Injection, Poor Medical Waste Management Fuel HIV, HPB Transmission, Say Experts'
142. The Times (2009, 22nd March) 'Used needles are causing a health crisis in India'
143. The Times ( 2009, 22nd March) 'Used needles are causing a health crisis in India'
144. Miller, MA & Pisani, E (1999) 'The cost of unsafe injections' of the World Health Organization, 77(10)