Home Current Issue Previous Issues Published Ahead-of-Print Collections For Authors Journal Info
Skip Navigation LinksHome > April 24, 2006 - Volume 20 - Issue 7 > Potential for HIV transmission through unsafe injections
AIDS:
doi: 10.1097/01.aids.0000222085.21540.8a
Research Letters

Potential for HIV transmission through unsafe injections

Apetrei, Cristiana,b; Becker, Josepha; Metzger, Michaela; Gautam, Rajeeva; Engle, Johna; Wales, Anne Katherinea; Eyong, Mc; Enyong, Peterc; Sama, Martync; Foley, Brian Td; Drucker, Ernestd; Marx, Preston Aa,b

Free Access
Article Outline
Collapse Box

Author Information

aTulane National Primate Research Center, Covington, Louisiana 70433, USA

bDepartment of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana 70112, USA

cMedical Research Station, Kumba, Cameroon, USA

dTheoretical Biology and Biophysics, Group T-10, Los Alamos National Laboratory, Los Alamos, New Mexico 87545, USA

eAlbert Einstein College of Medicine, Bronx, New York, USA.

Received 10 November, 2005

Revised 2 February, 2006

Accepted 24 February, 2006

Sponsorship: This work was supported by funds from grant RO1 AI-44596.

Collapse Box

Abstract

We tested for HIV in discarded needles and syringe washes from 191 HIV-infected patients receiving injections in rural Cameroon. HIV-1 RNA was amplified from 34 of 103 intravenous injection syringes and two of 88 intramuscular injection syringes. All 36 strains were HIV-1 group M. The majority belonged to the circulating recombinant form CRF02 (IbNg). Our data support a role for unsafe injections in the spread of HIV-1 in Africa, in contrast to recent studies.

HIV transmission through the reuse of needles and syringes may fuel the spread of HIV. Several epidemic outbreaks in eastern Europe [1,2] and Libya [3] have shown a rapid spread of HIV in nosocomial settings in the absence of standardized precautions. Moreover, transmission of HIV through contaminated needles and syringes was reported to contribute to the adaptation of cross-species transmitted SIVcpz and SIVsm to became the pathogenic HIV-1 and HIV-2, respectively [4,5]. A recent study carried out in Ethiopia failed to find HIV in used needle flushes [6]. Moreover, another study excluded unsafe injections as a major source of HIV infection in Africa [7]. Therefore, our aim was to investigate the risk of HIV transmission through unsafe injections using a more sensitive approach.

Matched blood and syringe washes were obtained from 191 HIV-infected patients receiving injections in 12 clinical settings in the southwest province of Kumba, Cameroon, in a 3-month period in 2001–2002. Written consent was obtained from all patients and the study was approved by the review board of the Medical Research Station, Kumba. The syringe washes were performed within 6 h of the syringe being used. The syringes were flushed with 1 ml RNA later (Ambion Inc., Austin, Texas, USA), which was drawn into the barrel and then flushed out through the needle. Blood specimens and syringe washes were preserved in ‘RNA later’. RNA and DNA were extracted from 500 μl of the syringe washes using a Qiagen QIAamp Viral RNA extraction kit (Qiagen, Valencia, California, USA). DNAses were not used, allowing the concomitant extraction of DNA. Control samples consisted of blood and syringe washes from 150 HIV-negative patients, tested under the same conditions. Reverse transcription (RT) polymerase chain reaction (PCR) or DNA PCR were performed on all samples using primer combinations targeting different structural genes as described [8]. PCR products were directly purified using a QiaQuick gel extraction kit (Qiagen). Sequences were obtained with an ABI Prism Dye Terminator Cycle Sequencing Ready Reaction kit with AmpliTaq DNA polymerase (Perkin-Elmer, Wellesley, Massachusetts, USA) on an automated sequencer (Applied Biosystems 373A, Foster City, California, USA) and submitted to GenBank (accession numbers: DQ452626–DQ452686).

The gag, pol and env nucleotide sequence alignments were obtained from the Los Alamos National Laboratory HIV Sequence Database (http://hiv-web.lanl.gov). Newly derived sequences were aligned with the reference sequences using CLUSTAL W [9] and adjusted manually. Regions of ambiguous alignment and all gap-containing sites were excluded. Phylogenetic trees were inferred from the nucleotide alignments by the neighbor-joining method [10].

No samples from HIV-negative patients were positive. A relatively high number of PCR on specific gene fragments were obtained by testing syringe washes from HIV-1-infected patients (Table 1). At least one genomic fragment was amplified from 36 of 191 HIV-1 seropositive specimens. Thirty-three per cent (34 out of 103) of the syringes used for intravenous injections in HIV-seropositive individuals contained amplifiable virus. Only 2% (two out of 88) of the syringes used for intramuscular injections contained amplifiable virus. This is not surprising because the exposure to blood during intramuscular injections is significantly lower than in the case of intravenous injections. However, these results show that there is a risk of HIV transmission even in the case of intramuscular injections.

Table 1
Table 1
Image Tools

PCR results with different primer sets are shown in Table 1. The most sensitive PCR assay targeted the protease gene: 29 samples were positive in this region. Fifteen samples were positive in RT, 13 in env and 17 in gag. These differences in PCR efficacy were probably related to the first round PCR for RT, env and gag targeted larger amplicons.

In phylogenetic trees (data not shown), the majority of the gag sequences clustered with CRF02 (n = 12); the remaining ones clustered with subtypes D (n = 1), F2 (n = 1) and K (n = 1) and CRF11 (n = 1). Out of the 27 protease sequences, 19 clustered with CRF02, two with subtype D (n = 2), four with CRF01 and two with CRF11. Most of the RT sequences clustered with CRF02 (n = 10), the remaining one clustering with subtype A1 (n = 2) and CRF11 (n = 1). Finally, env sequences clustered with CRF02 (n = 10), and subtypes D (n = 2) and A1 (n = 1).

Out of the 18 strains for which at least two genomic fragments were available, 13 strains exhibited a similar subtype but clustering in different trees: 12 CRF_02, 1 D (Table 1). Three of the remaining sequences showed a discordant clustering pattern: two sequences were Apol/Denv, whereas one was F2gag/Apol/Aenv. Two strains showed only slight variations between different trees: strain Cam669 clustered within the CRF11 subcluster in gag and pol trees and within the CRF02 subcluster in env. In the V3–V5 region both CRF11 and CRF02 have a subtype A structure [11–14]; similarly, Cam532 clustered with CRF02 strains in pol and with subtype A1 in env. In this region CRF02 has an A1 structure [13,14]. Altogether, our results showed a relatively limited HIV-1 diversity in syringe washings from the southwest province of Cameroon. Few unique recombinant forms were detected in our study. The major form identified is CRF02, which was recently reported to be expanding in west-central Africa [15]. This is not surprising, because CRF02 was shown to be the dominant viral form in the epidemics in west-central Africa [15].

Transmission through unsterilized and reused needles and syringes was claimed to be a significant cause of HIV infection in Africa [16]. However, it was recently reported that ‘unsafe medical injections can be confidently excluded as a major source of HIV infection’ [7]. Studies of HIV survival in syringes have been carried out in western countries [17], and clearly showed a risk of HIV transmission through unsafe injections. Therefore, it was important to carry out controlled studies under real-world conditions to prove or disprove the theory that injections were safe, especially in resource-poor settings. This is the first such study showing the presence of potentially infectious HIV in needles and syringes in a real-world situation. Previous attempts failed to amplify HIV in discarded syringes in Ethiopia [6]. Our strategy of collecting syringe washes immediately after syringe use and of extracting DNA/RNA from relatively large amounts of material may account for our results compared with previous studies.

A large number of ‘clinics’ exist in sub-Saharan Africa and their policies for injections are not subjected to systematic control. Therefore, they represent a potential risk of nosocomial transmission of HIV. By showing that HIV-1 RNA was present in more than 30% of syringes used for intravenous injections, we provided proof of concept that injection practices could account for a significant proportion of new HIV infections. PCR amplification of viral nucleic acid demonstrated that a high viral level was present in the syringe wash, certainly enough to transmit HIV [18]. Although some have argued that viral nucleic acid presence does not necessarily demonstrate viable viral presence, it does demonstrate that viable virus could be present, or at least, had been present. Therefore, our results show that caution must still be exercised and that the belief that HIV may not be transmitted by re-used needles is dangerous to public health initiatives.

Back to Top | Article Outline

References

1. Bobkov A, Garaev MM, Rzhaninova A, Kaleebu P, Pitman R, Weber JN, Cheingsong-Popov R. Molecular epidemiology of HIV-1 in the former Soviet Union: analysis of env V3 sequences and their correlation with epidemiologic data. AIDS 1994; 8:619–624.

2. Apetrei C, Necula A, Holm-Hansen C, Loussert-Ajaka I, Pandrea I, Cozmei C, et al. HIV-1 diversity in Romania. AIDS 1998; 12:1079–1085.

3. Yerly S, Quadri R, Negro F, Barbe KP, Cheseaux JJ, Burgisser P, et al. Nosocomial outbreak of multiple bloodborne viral infections. J Infect Dis 2001; 184:369–372.

4. Drucker E, Alcabes PG, Marx PA. The injection century: massive unsterile injections and the emergence of human pathogens. Lancet 2001; 358:1989–1992.

5. Marx PA, Alcabes PG, Drucker E. Serial human passage of simian immunodeficiency virus by unsterile injections and the emergence of epidemic human immunodeficiency virus in Africa. Philos Trans R Soc Lond B Biol Sci 2001; 356:911–920.

6. Priddy F, Tesfaye F, Mengistu Y, Rothenberg R, Fitzmaurice D, Mariam DH, et al. Potential for medical transmission of HIV in Ethiopia. AIDS 2005; 19:348–350.

7. Lopman BA, Garnett GP, Mason PR, Gregson S. Individual level injection history: a lack of association with HIV incidence in rural Zimbabwe. PLoS Med 2005; 2:37.

8. Pandrea I, Robertson DL, Onanga R, Gao F, Makuwa M, Ngari P, et al. Analysis of partial pol and env sequences indicates a high prevalence of HIV type 1 recombinant strains circulating in Gabon. AIDS Res Hum Retroviruses 2002; 18:1103–1116.

9. Thompson JD, Higgins DG, Gibson TJ. CLUSTAL W: improving the sensitivity of progressive multiple sequence alignment through sequence weighting, position-specific gap penalties and weight matrix choice. Nucl Acids Res 1994; 22:4673–4680.

10. Swofford D. PAUP*. Phylogenetic analysis using parsimony (*and other methods). In: Version 4 ed. Sunderland, Massachusetts: Sinauer Associates; 1999.

11. Paraskevis D, Magiorkinis M, Paparizos V, Pavlakis GN, Hatzakis A. Molecular characterization of a recombinant HIV type 1 isolate (A/G/E/?): unidentified regions may be derived from parental subtype E sequences. AIDS Res Hum Retroviruses 2000; 16:845–855.

12. Montavon C, Vergne L, Bourgeois A, Mpoudi-Ngole E, Malonga-Mouellet G, Butel C, et al. Identification of a new circulating recombinant form of HIV type 1, CRF11-cpx, involving subtypes A, G, J, and CRF01-AE, in Central Africa. AIDS Res Hum Retroviruses 2002; 18:231–236.

13. McCutchan FE, Carr JK, Bajani M, Sanders-Buell E, Harry TO, Stoeckli TC, et al. Subtype G and multiple forms of A/G intersubtype recombinant human immunodeficiency virus type 1 in Nigeria. Virology 1999; 254:226–234.

14. Carr JK, Salminen MO, Albert J, Sanders-Buell E, Gotte D, Birx DL, McCutchan FE. Full genome sequences of human immunodeficiency virus type 1 subtypes G and A/G intersubtype recombinants. Virology 1998; 247:22–31.

15. Montavon C, Toure-Kane C, Liegeois F, Mpoudi E, Bourgeois A, Vergne L, et al. Most env and gag subtype A HIV-1 viruses circulating in West and West Central Africa are similar to the prototype AG recombinant virus IBNG. J Acquir Immune Defic Syndr 2000; 23:363–374.

16. Gisselquist D, Minkin SF, Okwuosah A, Salerno L, Minja-Trupin C. Unsafe injections and transmission of HIV-1 in sub-Saharan Africa. Lancet 2004; 363:1648–1649, author reply 1649–1650.

17. Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr 1992; 5:1116–1118.

18. Rich JD, Dickinson BP, Carney JM, Fisher A, Heimer R. Detection of HIV-1 nucleic acid and HIV-1 antibodies in needles and syringes used for non-intravenous injection. AIDS 1998; 12:2345–2350.

Cited By:

This article has been cited 14 time(s).

International Journal of Std & AIDS
Factors associated with HIV prevalence in a pre-parturn cohort of Zambian women
Lawrence, JSS; Klaskala, W; Kankasa, C; West, JT; Mitchell, CD; Wood, C
International Journal of Std & AIDS, 17(9): 607-613.

Medical Hypotheses
Comments on the serial-passage hypothesis of HIV evolution
Parris, GE
Medical Hypotheses, 68(4): 914.
10.1016/j.mehy.2006.09.042
CrossRef
Medical Hypotheses
Mechanism and history of evolution of symbiotic HIV strains into letha; pandemic strains: The key event may have been a 1972 trial of pamaquine in Leopoldville (Kinshasa), Congo
Parris, GE
Medical Hypotheses, 69(4): 838-848.
10.1016/j.mehy.2007.01.073
CrossRef
International Journal of Std & AIDS
Minimum infective dose of HIV for parenteral dosimetry
Reid, S; Juma, OA
International Journal of Std & AIDS, 20(): 828-833.
10.1258/ijsa.2009.009284
CrossRef
International Journal of Std & AIDS
Increase in clinical prevalence of AIDS implies increase in unsafe medical injections
Reid, S
International Journal of Std & AIDS, 20(5): 295-299.
10.1258/ijsa.2008.008441
CrossRef
Harm Reduction Journal
Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review
Reid, SR
Harm Reduction Journal, 6(): -.
ARTN 24
CrossRef
International Journal of Std & AIDS
Considering causality: a response to Muula
StLawrence, JS
International Journal of Std & AIDS, 18(4): 289.

Annals of Epidemiology
Lack of autodisable syringe use and health care indicators are associated with high HIV prevalence: An international ecologic analysis
Deuchert, E; Brody, S
Annals of Epidemiology, 17(3): 199-207.
10.1016/j.annepidem.2006.09.005
CrossRef
AIDS
HIV-contaminated syringes are not evidence of transmission
Lopman, BA; French, KM; Baggaley, R; Gregson, S; Garnett, GP
AIDS, 20(): 1905.

International Journal of Std & AIDS
Injection risks and HIV transmission in the Republic of South Africa
Reid, S; Van Niekerk, AA
International Journal of Std & AIDS, 20(): 816-819.
10.1258/ijsa.2009.009230
CrossRef
JAIDS Journal of Acquired Immune Deficiency Syndromes
Time Trends and Regional Differences in the Prevalence of HIV Infection Among Women Attending Antenatal Clinics in 2 Provinces in Cameroon
Kuate, S; Mikolajczyk, RT; Forgwei, GW; Tih, PM; Welty, TK; Kretzschmar, M
JAIDS Journal of Acquired Immune Deficiency Syndromes, 52(2): 258-264.
10.1097/QAI.0b013e3181ab6d2e
PDF (153) | CrossRef
Sexually Transmitted Diseases
Network-Light Not Data-Free
French, KM; Riley, S; Garnett, GP
Sexually Transmitted Diseases, 34(1): 57-58.
10.1097/01.olq.0000253173.47544.d7
PDF (79) | CrossRef
Sexually Transmitted Diseases
Data-Free Modeling of HIV Transmission in Sub-Saharan Africa
Brewer, DD; Rothenberg, RB; Potterat, JJ; Muth, SQ
Sexually Transmitted Diseases, 34(1): 54-56.
10.1097/01.olq.0000249725.60291.ce
PDF (114) | CrossRef
JAIDS Journal of Acquired Immune Deficiency Syndromes
Association of HIV Infection With Poor Genital Hygiene and Medical Treatment for Prior Serious Illness Suggests Iatrogenic Transmission
Brody, S; Brewer, DD; Potterat, JJ
JAIDS Journal of Acquired Immune Deficiency Syndromes, 44(3): 365-366.
10.1097/QAI.0b013e31802ea4f1
PDF (98) | CrossRef
Back to Top | Article Outline

© 2006 Lippincott Williams & Wilkins, Inc.

Login