The HIV epidemic in Africa is assumed to be related primarily to heterosexual transmission and mother-to-child transmission. However, several lines of evidence suggest that medical injections may account for more HIV transmission than previously estimated [1–9]. Ethiopia has an estimated HIV prevalence of 6.6%, and 38–77% of adult men surveyed had had more than one medical injection in the previous year [10–13]. Because Ethiopia has a significant HIV epidemic and a high frequency of potentially risky medical injections, we conducted a descriptive study of the potential for the medical transmission of HIV through unsafe medical injection practices.
During September and October 2002, medical providers and clients were interviewed in the local language about injection safety at 16 rural health institutions along major trucking routes outside the capital, Addis Ababa. Medical injection practices were observed and recorded using established World Health Organization (WHO) safe injection global network survey instruments . The adequacy of needle sterilization and disposal equipment was analysed. HIV seroprevalence was determined from a random sample of patients after obtaining oral informed consent. Blinded HIV testing was performed on finger stick dried blood specimens using Vironostika Uni-Form II plus O (BioMerieux, Durham, NC, USA).
We collected 212 used, disposable intramuscular injection needles, which had been previously used and prepared for re-use by health institution staff. Preparation for re-use consisted of separating the needle from the syringe and boiling the needle and syringe in water for an indeterminate amount of time. These used needles were reattached to a sterile syringe and flushed and rinsed on-site with 0.5 ml RNAlater (Ambion, Austin, TX, USA) an RNA stabilization solution that preserves RNA at 25 °C for one week. Samples were maintained at less than 25 °C in the field and frozen at −20 °C within 7 days. Samples were later analysed for the presence of HIV RNA by nucleic acid sequence-based amplification (NucliSens HIV-1 QT version 1.0; BioMerieux). The study was approved by the ethics committees of Emory University and Addis Ababa University.
Dried blood spots on filter paper were collected from 72 patients in eight health centres. Ages ranged from 16 to 75 years; 50% were women; 8.3% (six) were HIV positive (95% confidence interval 3.9–17.0).
Sixteen outpatient health centres and health stations were included. Therapeutic injections were usually given with 5 or 10 cc disposable single-use syringes with a 20 gauge detachable 3.8 cm needle. These syringe/needles were available in local pharmacies for US¢6. Vaccinations were given with sterilizable syringes and needles from an EPI immunization kit used exclusively for vaccinations or disposable single-use syringe/needles. Eight out of 13 health institutions (62%) reported re-using disposable needle/syringes for therapeutic injections. All institutions used steam sterilizers to prepare EPI needle/syringes; however, 13 out of 16 (81%) did not operate the sterilizers according to WHO guidelines.
We observed 260 therapeutic injections and vaccinations. In 124 (48%), patients brought a new, disposable syringe for use. However, 32 of observed injections (12%) were given with a used, disposable syringe that had been prepared for re-use. These disposable needle/syringes were prepared for re-use with a steam sterilizer or by boiling. Therapeutic injections were more likely than vaccinations to be given with disposable syringes; however, a small proportion of both therapeutic injections and vaccinations were given with re-used disposable needle/syringes. Injections at health stations were much less likely to be given with patient-purchased disposable syringe/needles and much more likely to be given by re-used disposable syringe/needles than those at health centres (Table 1).
Of 440 patients surveyed, 203 (46%) had received a therapeutic injection in the past 3 months. A total of 277 (63%) preferred oral treatment over injection, 388 (88%) were aware that ‘dirty syringes can transfer disease’, and 347 (79%) spontaneously mentioned HIV as a disease transferred by dirty needles. Of 56 injection prescribers surveyed, primarily nurses or health assistants, 46 (82%) felt that patients preferred injections.
Five out of 16 facilities (31%) had sharps disposal boxes in the injection area, whereas eight (50%) had open wastebaskets for sharps disposal that were dirty or overflowing. Only five (31%) had a designated incinerator, and three (19%) dumped sharps in an unsupervised area without burning. At 12 facilities (75%), exposed, used needles were found on the grounds.
Nucleic acid sequence-based amplification analysis of 212 used needle flushes showed no evidence of HIV RNA. The NucliSens QT assay has a lower limit of detection of 80 copies/ml or 0.08 copies/μl. We assumed that each needle may retain at least 1 μl blood, which was diluted with 500 μl RNAlater. Therefore, this protocol would be unable to detect HIV RNA from patients with viral loads less than 40 000 copies/ml.
In a high HIV prevalence area in Ethiopia, we found the re-use of disposable syringe/needles for both therapeutic injections and vaccinations. No evidence of immediate needle/syringe re-use from patient to patient was observed. However, despite the fairly high use of patient-purchased disposable needles, 12% of therapeutic injections were given with previously used disposable needles. Poor ‘sterilization’ practices were common, with 70% of vaccinations administered using EPI needle/syringes that had not been properly sterilized according to WHO safe injection guidelines.
Patients had high levels of knowledge about injection risks, and reported only moderate demand, but medical providers believed that patients prefer injections. This attitude may be responsible for the continued high rates of medical injections in Ethiopia.
An analysis of used needles showed no evidence of HIV RNA. This study is the first to attempt to detect the presence of HIV viral material on injection equipment in a clinical setting in the field. Whereas a larger sample size and more sensitive HIV RNA assay may be necessary to detect very small amounts of the virus in used intramuscular injection needles, our findings suggest that medical injection practices in this region do not contribute significantly to HIV transmission. Anecdotally, patients and providers attributed the popularity of patient-purchased disposable needle/syringes to public radio announcements promoting their use. Single-use, disposable needle/syringes should continue to be promoted and made available at low cost. Further study of medical injection practices as well as traditional medicine and scarification practices is warranted to evaluate the potential for HIV transmission in higher prevalence areas.
Sponsorship: This work was supported by the National Institute of Allergy and Infectious Disease, National Institutes of Health (NIAID/NIH), Bethesda, MD, USA. The authors declare no conflicts of interest.
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