Wednesday, October 13, 2010

Could a Nosocomial HIV Outbreak Occur in Kenya?

One of the most horrifying examples of a nosocomial HIV outbreak occurred in Romania in the 1980s. According to a recent article in Time:

"Unlike in the rest of Eastern Europe, the majority of people living with HIV in Romania did not become infected as adult drug users or sex workers, but as children living in orphanages. In 1987, nurses hoping to cure Romania's orphans of their anemia started injecting them with whole-blood transfusions daily, reusing syringes on multiple children. Some of the blood turned out to be contaminated and at least 10,000 orphans contracted HIV. By 2000, Romania claimed 60% of all the pediatric HIV infections registered in Europe."

There have been many other nosocomial outbreaks, before and since, the majority of them remaining relatively undocumented. However, the basic details of some of the worst are listed in various places on the web, in particular, in David Gisselquist's book 'Points to Consider', available online, free of charge.

In many countries where nosocomial HIV (and other blood-borne diseases, such as hepatitis) outbreaks occurred, they were related to blood transfusions and the use of other blood products. Such occurrences in Western countries are now far less likely to happen, perhaps extremely unlikely. And even in developing countries there is greater awareness of the risks associated with blood transfusions. Most blood is screened, but it is unlikely that all countries take all precautions necessary to ensure that these risks are completely eliminated, especially developing countries.

And when it comes to unsafe injections, it is particularly difficult to quantify the risk. The WHO estimates that about 70% of injections are unnecessary and that a high percentage are unsafe, maybe close to 20%, maybe higher. The figures they cite usually lump countries together in regions and sub regions, so it's hard to know what figures apply to which countries.

UNAIDS is usually silent on the issue of non-sexual transmission of HIV, and nosocomial transmission of HIV, in particular. There are two notable exceptions; the first is when they publish figures denying that nosocomial transmission contribute more than about 2.5% of infections to epidemics in countries such as Kenya; the second is when they warn UN employees to avoid medical facilities in countries such as Kenya because of the risk of nosocomial infection with HIV or other blood borne diseases. It would be truly a medical miracle if only non-Kenyans (and non-Africans) were susceptible to such risks.

Evidence that HIV has been transmitted in African countries is  not hard to find and 'Points to Consider' is a good place to start. But the HIV orthodoxy remains, that HIV transmission is almost all heterosexual in African countries. It appears that evidence to the contrary is being systematically ignored. Why this is so is very unclear.

But rather than constantly drawing together the evidence (a quick search for 'nosocomial' on my blog links to plenty of citations where evidence can be evaluated), it is time for the issue to be investigated. The investigation needs to assess how much HIV has been transmitted nosocomially in the past and to ensure that it no longer happens in the future. At present, most 'official' figures, are modeled. These models first assume, without adequate evidence, that almost all HIV transmission is through heterosexual sex. Then these 'officials', in their infinite wisdom, allocate a small percentage that is nosocomial.

Given what is known about probabilities of heterosexual HIV transmission, it is not possible for the virus to spread as quickly as it has in some African countries (though not all). But given what is known about nosocomial infections, the Romanian instance being just one, it is possible for HIV to spread rapidly in countries that have very poor health services.

Kenya has very poor health services but a lot of people don't have access to health facilities. However, many of the countries with the highest rates of HIV transmission have poor health services to which a large percentage of the population have access. There is an opportunity to investigate and possibly eliminate a substantial percentage of HIV transmission.

Perhaps it's a matter of professional pride or academic pigheadedness that prevents UNAIDS and other parties from even admitting the possibility that they are wrong. But, whatever the reason, the possibility must be acknowledged. Otherwise, many more people will be infected with HIV and other viruses, leading to a lot of unnecessary and preventable suffering and death. What happened in Romania in the 1980s could happen in many African countries in the 2000s. It could happen in Kenya.

(To read about pre-exposure prophylaxis (PrEP), see you other blog.)


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