Parenteral HIV transmission in India

[Guest guest]

Dear fellow members,

Recently we have had a lot of discussion about the parenteral transmission in

India.

[Parenteral transmission is defined as that which occurs outside of the

alimentary tract, such as in subcutaneous, intravenous, intramuscular, and

intrasternal injections. Moderator]

I would offer two comments about the same:

1. Safe injection practices in particular and other safety in health care in

general are an absolute must in all health care facilities (private or public)

and should be treated as a basic right of the patients. People in the field of

HIV and outside it should collectively strive for the same.

2. We need to examine the contension about the parenteral spread of HIV more

closely. Even taking the reports of the nationwide INCLEAN survey as baseline

let us do some rough calculations.

1,890,000,000 unsafe injections per year Overall HIV prevalence 0.8% in adults.

Without adjusting for the adult / child injections " What would be the

possibility of previous injection being high risk? " even at far fetched 1% this

would mean that 18,900,000 injections could be " high risk " .

At 0.3% probability of actual HIV transmission number of infections would be

around 54,000. Out of total approx 500,000 infections this is about 10%.

That is where we usually place parenteral transmission. Unsafe blood

transfusions less than 5%, unsafe injection practices at 10%, MTCT less than 5%

and remaining > 80% unsafe sex.

That or mostly around that stands the long standing knowledge. Now what and why

this noise about?

May be my calculations are wrong may be ther could be a better model. Please

come out with it.

THIS DOES NOT REDUCE THE IMPORTACE OF SAFE INJECTION PRACTICES AT ALL but we

need to know the rationale.

Hope this starts some debate on the forum.

PRAYAS,

Pune

e-mail: <prayashealth@...>

[Guest guest]

Dear Friends at Prayas,

Thanks for your question. There are approximately 5 million HIV-positive people

in India. Most do not know they are infected, and no doctor, dentist, or

tattooist can know just by looking at them.

From InCLEN, the average Indian receives 5.8 injections per year. People living

with HIV receive more injections and visit health facilities more often than

people without HIV infection. They may go for dental care, tattoos, laparoscopic

surgery, ear and nose piercing, blood tests, and other procedures.

Adding everything together, an average HIV-positive person could have 10-15

invasive procedures per year.

Next, consider the risk from a single event. Studies of health care workers

after needlestick accidents with equipment used on an HIV-infected patient show

that 3 in 1,000 become infected. HOWEVER, most

needlestick accidents are shallow scratches that do not pierce the skin. Less

than 7% are " deep " injuries, which means the hole of the needle goes into the

skin, as in an injection. For deep injuries the average risk is 2.3%.

So, here are some calculations: 5 million HIV positive people in India receive a

total of 50-75 million invasive procedures per year.

How often are instruments reused without sterilizaton? Let's suppose it's

between 20% to 33%.

What is the risk to transmit for all of the various procedures? This varies a

lot by procedures, eg, low for reusing lancets to prick fingers for blood tests,

high for laparoscopic surgery. Let's suppose the average is 0.5% to 3% per

event.

Combining, we get a low estimate of 50 million events x 20% of instruments

reused without sterilization x transmission after 0.5% of these events = 50,000

new HIV infections per year.

We get a high estimate of 75 million x 33% x 3% = 750,000 new HIV infections per

year. Because we know so little about these risks, the true figure might be

lower or higher than this range.

In any case, what this says is that blood exposures might account for most new

HIV infections in India. Furthermore, we cannot be confident that India's HIV

epidemic is contained until infection control is

rigorously observed for all invasive procedures.

The best way to find out about risks with blood exposures is to investigate

unexplained infections -- for example, HIV-positive children with HIV-negative

mothers. We urge reporters to find and report unexplained cases -- they are not

hard to find. We urge lawyers to work with parents' groups to ask for

investigations.

When one child has been infected, and no one finds out where it came from and

fixes the situation, maybe others will be infected. If you are interested to

help promote investigations, please join RELASH (REporters and LAwyers for Safe

Healthcare) at RELASH-subscribegroups (DOT)

Best regards,

Gisselquist

e-mail: <david_gisselquist@...>

Mariette Correa

e-mail: <mariettec@...>