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Overstating the case for blood-borne transmission

There is a definite case for curtailing the spread of blood-borne HIV by medical practitioners and bringing the prevalence of this iatrogenic spread of HIV to zero. But the authors are overstating the case when there is no need to do so, says Dr Anant Phadke

Blood Borne HIV: Risks and Prevention by Mariette Correa, David Gisselquist, and Deodatta Gore, is an outcome of the authors’ more than decade-long effort to draw attention to the prevalence of blood-borne HIV infection in India. One of the central points of this book is that in India the blood-borne transmission of HIV has not received the attention it deserves.

The authors feel that because the National Aids Control Organisation (NACO) estimated that in India 86% of the HIV spread is through the sexual route, the blood-borne transmission of HIV has been underplayed and that there has been too much emphasis on the sexual route of transmission of HIV. The authors have, however, not presented any evidence to back up this claim of ‘over-emphasis’.

Unless appropriately and indefinitely treated, HIV infection is fatal within a few years. Hence, even if only 14% of HIV cases are blood-borne as per NACO figures, this is certainly a matter to be taken very seriously. The 14% blood-borne cases include unsterilised needles/syringes and other forms of parenteral transmission – transfusions of HIV infected blood and mother-to-child transmission. But even if the prevalence of HIV transmission through unsterilised needles/syringes is, say, only 10%, it is still completely unacceptable and attempts must be made to reduce it through safe injection practices or by taking standard precautions. To emphasise the measures to stop the blood-borne transmission of HIV, there is no need to prove that a particular percentage of HIV spread, say 25%, is blood-borne.

The authors’ arguments in support of their claim that probably a higher proportion of HIV transmission is blood-borne than is believed, are not convincing. They have argued that, for example, in developed countries, despite high promiscuity, HIV prevalence in the general population has remained very low, “often less than 0.1%” and is generally confined to men having sex with men (MSM) and intravenous drug users because medical procedures in these countries are almost always done under aseptic conditions. In India, however, since injections are quite often given with unsterilised needles/syringes, the HIV epidemic has spread much more widely, though sexual promiscuity is no higher in India. They feel that in fact many cases of infection that are assumed to be due to unsafe sex may well be due to unsafe injections, but nobody bothers to ask these HIV-positive people whether they had also received an unsafe injection.

This last point may well be true but the authors don’t take into account the fact that developed countries have 100% literacy and hence much more awareness about the dangers of unsafe sex. This can explain, to a large extent, the low HIV prevalence in these countries along with virtual absence of unsafe medical interventions. If, both, awareness that HIV spreads through unsafe sex as well as the prevalence of condom use were to be as high in India as in the developed countries, then we could have inferred that the generalised spread of HIV in India is to a larger extent blood-borne, given the fact that in India sterilisation of syringes/needles is a horribly neglected area especially amongst unqualified and irresponsible doctors of whom there are many. But the authors have not presented any comparative data about AIDS awareness and condom use. 

One more way to examine the authors’ hypothesis would be to compare HIV prevalence in the pre-adolescent and the adult population. Since children get many more injections than adults (due to immunisations and for frequently occurring fevers etc), whatever HIV prevalence is there in children would be all due to injections or due to mother to child transmission at birth from HIV-positive mothers, as sexual spread is almost zero in this age group. But the authors have not presented any such data. 

I think the authors are overstating the case, that too, without credible evidence, when there is no need to overstate the case in the first place. Even if “only”14% of HIV cases are blood-borne, this is unacceptably high. 

The authors have drawn attention to the fact that not only unsterilised syringes and needles, but also the use of multi-dose vials can be a source of transmission of HIV if the syringe used to inject the patient is re-used to draw medicine from the vial. There has to be much more vigilance to ensure that this dangerous practice is eliminated. Many ‘doctors’ and nurses still use the same syringe for a number of patients and change only the needle. The authors have rightly criticised this dangerous practice. Same is the case with the criminal practice of using improperly sterilised laparoscopes in tubectomy camps. Not only quacks but some highly educated doctors indulge in this dangerous practice. 

A positive feature of this book is that it systematically discusses each of the possible mechanisms of HIV transmission and suggests specific measures to avoid this risk. It covers a whole range of situations from unsafe sex to receiving injections to taking care of AIDS patients. However, this section is a little too lengthy and somewhat boring. Each of the 15 such possible “risky” encounters are first described in some detail, the risk involved is stated and protective steps are suggested. The class of readers who would read this book, which is in English, would hardly go to doctors who reuse without sterilisation an intravenous infusion set or who would use unsterilised needles/syringes to draw blood for doing laboratory tests, or to gynaecologists who would do vaginal examinations with “unwashed hands”. Second, the risks and protective measures are bound to be repetitive and hence boring to read. This material could have been presented in a shorter and more user-friendly way, as for example, in the form of a table.

As a protective measure against blood-borne HIV transmission, the authors have advocated, like most others, the use of disposable syringes and needles. Some of us have been arguing that ensuring that syringes/needles are boiled before use is a much more sensible, economical and eco-friendly measure. The HIV virus is killed within a couple of minutes by boiling, though 20 minutes boiling is needed to eliminate the hepatitis B virus. It’s a matter of utter shame that doctors cannot ensure that proper boiling is done in their clinics/hospitals. Moreover, in India, one cannot be sure that a disposable syringe/needle is sterile.

Despite certain limitations, this book is a much needed reminder that we must prevent the spread of blood-borne HIV by medical practitioners and bring the prevalence of this iatrogenic spread of HIV to zero. This should be a mandatory goal for medical practitioners.

(Blood Borne HIV: Risks and Prevention by Mariette Correa, David Gisselquist, Deodatta Gore, Orient Longman, Chennai, 2008 pp 91, price Rs 95) 

(Anant Phadke is co-ordinator of SATHI-CEHAT, a leading NGO in the Peoples'Health Movement in India, and is associated with a number of health and science organisations. He has written extensively in English and Marathi onissues related to the people's science and health movement)

InfoChange News & Features, February 2009