Newsday - June 19, 2001
Laurie Garrett, Staff Writer
THE MOST CRUCIAL strategy in the war on AIDS is prevention of further HIV infection, and activists and policy-makers are questioning why more vigorous efforts in that arena haven't been pursued.
In societies that now have infection rates exceeding 10 percent of adults, for example, blood supplies remain largely untested, medical syringes continue to be reused in nonsterile manners and mother-to-child transmission of the virus isn't being prevented.
Globally, critics charge, such basic steps as promotion of condom use and sex education of pre-adolescents have not been seriously implemented.
Timothy Wirth, president of the United Nations Foundation, an organization funded by Ted Turner, said in an interview that the foundation has decided to focus all of its HIV/AIDS portfolio on prevention efforts. Topping their concerns is a crisis in the global supply of condoms, which Wirth said stems in part from a decline in funding for bulk purchases of condoms to be distributed in poor countries, coupled with a concurrent explosion in the sexual spread of HIV. Adding to the problem, he said, is "the largest group of young people entering the reproductive age that has ever been seen in history."
In May, Wirth met in Istanbul with representatives of family planning organizations, AIDS prevention groups, condom manufacturers and UN agencies. The gathering concluded that "this is first among equals in terms of priorities for action," Wirth said. "The overall shortfall is in the neighborhood of $100 million" for purchase of billions of condoms, he said.
Other groups are drawing attention to another means of spreading HIV -- the global blood supply.
In wealthy nations, all blood donations are, by law, screened for contamination by HIV, hepatitis B, hepatitis C and other microbes. The screening has proven so effective, according to the Centers for Disease Control and Prevention, that the odds of acquiring HIV from U.S. blood transfusions approaches zero.
But worldwide this is not the case, according to the World Health Organization. Less than 10 percent of all blood transfusions last year were screened for HIV contamination.
Blood is big business all over the world, experts at WHO say, operating both officially and on the black market. Late last year, for example, WHO uncovered a scheme involving the sale of HIV- and hepatitis-contaminated blood from South Africa to blood banks in China and India. Some made its way to England, where it was seized by British authorities. In 1996, Austrian authorities seized thousands of liters of HIV-positive blood that a company was attempting to dump on Third World markets.
In India and China, in particular, hundreds of millions of dollars' worth of black market blood exportation and trade transpires every year; none of that blood is tested for HIV. China's Ministry of Health has admitted that the country has an unusually high number of blood bank-associated HIV cases, but declines to offer details. The Beijing Morning Post has reported that large blood product operations in Shanghai, Lanzhou, Wuhan, Beijing and Changchun are collecting and distributing untested blood. Three of these plants, according to humanitarian relief organization sources who spoke on condition they not be identified, also make blood clotting factors used to treat hemophilia. In some cases the donors have been infected because of nonsterile equipment and procedures.
At the World Health Organization, Dr. Jean Emmanuel is in charge of clearing up the world's blood supply. A native Zimbabwean, Emmanuel managed to keep his own country's blood supply HIV-free, even as the African nation's overall HIV rate soared, now approaching 25 percent of all adults.
"Eighty percent of the people in the world have access to only 20 percent of the safe blood in the world," Emmanuel said in an interview at the Geneva headquarters of WHO. "And the key impediments are the lack of true government support to establish nationally coordinated systems [for screening]. So, basically, nobody is in charge."
In poor countries, Emmanuel argues, the best plan is one that puts all blood collection, processing and testing in one or two large cities, and has a strong chain of order "that ensures that the right blood gets to the right patient, tested and safe."
But the logistics of moving that blood is a nightmare, Emmanuel says, noting that few poor countries have decent roads, ample gasoline or reliable delivery services.
"You can see people oversimplifying the whole blood safety issue," he said. "We know that blood costs about $30 to $60 per unit when you add up all the costs, from the donor to the patient. But one unit of safe blood can instantly save your life."
And the incremental cost of testing the blood is not high compared with the price society pays as HIV spreads, he said.
In malaria-hit countries of Asia and Africa, the blood problem is compounded by the need for transfusions because children develop acute anemia in response to a weak drug regimen that treats malarial parasites. In rural areas, these transfusions are rarely tested for HIV.
"The subject of blood transfusion is emblematic of the whole problem," said Dr. Kevin DeCock, head of the CDC's operations in East Africa. It's "fixed rapidly in the industrialized world, taken for granted as being fixed everywhere else. Yet in Africa, far, far from resolved."
Similarly, syringes and hospital equipment, which are generally safe in wealthy countries, rarely are so in the rest of the world.
In Nigeria, Dr. Wuraola Shokunbi of the University College Hospital in Ibadan estimates that as much as 10 percent of all HIV transmission is due to contaminated blood products and transfusions. And surveys in villages, she says, show that between 10 and 58 percent of the HIV-positive children acquired their infections as a result of contaminated transfusions, most delivered for malaria treatment.
Two months ago, the CDC reported that last year 12 billion injections worldwide were given for reputed medicinal purposes: 10 percent for vaccinations and the rest for treatments. The CDC estimates that three out of every four were medically unnecessary. And 80 percent of the injections in Southeast Asia and Africa involved reused, nonsterile syringes. In eastern Europe, Russia and the other former Soviet Union nations, 70 percent of all medical injections are nonsterile.
Dr. David Heymann, who now heads the communicable disease control efforts at WHO, proved a decade ago that reuse of nonsterile syringes on pediatric wards in Romania in 1989 sparked that country's AIDS epidemic. In one year, Romania's reported number of HIV cases jumped from 13 to 1,168; 94 percent of that increase was in children less than 13 years old.
In Russia, Heymann and his Russian collaborators found that syringes reused on obstetric wards in 1988 and 1989 started a chain of HIV transmissions that included at least 197 pre-teen children.
Spread of infection within a medical setting is called nosocomial disease -- and any such outbreak is, in the rich world, considered evidence of shameful practices within a hospital. But the Romanian nosocomial HIV outbreaks, Heymann wrote in the journal AIDS, "do not appear to have provided the stimulus necessary for lasting change in infection control."
Australian researcher Kathleen Kay, one of the founders of WHO's AIDS program in 1987, has been doing HIV control consulting work in Asia.
In an e-mail interview, Kay said in China she inquired about sterilized syringes, "and they told me to use methylated spirits. They had single packed plastic syringes with attached needles. However, I later discovered that these sterilization procedures, as they said, æneed strengthening,' and the pharmacies more often than not washed and repackaged previously used syringes."
Last year, Newsday reported on immunization days in clinics in Uganda and Tanzania where small children lined up and got their shots -- all from the same needle. This occurred in villages where HIV rates were about 20 percent.
"What makes it even more difficult is that traditional practitioners, of all types, also treat with injections," Dr. Allan Rosenfeld, dean of the Columbia University School of Public Health. "Stopping these practices is a massive challenge.
AIDS specialist Robin Weiss, of University College London, calls the nonsterile needle issue "a nosocomial armageddon" and notes that the needle-infected individual can then pass the virus on sexually. So, he concludes, each needle-poke could expand to involve dozens of people, spreading HIV at a radical pace.
There are solutions to the syringe problem, advocates say: autodestruct syringes, which hold the needle inside the plunger after one injection, making reuse impossible.
"The clean syringe issue is critical," said AIDS researcher John Moore of Cornell University Medical Center in Manhattan. "It's pathetic that a simple, low-tech, relative cheap solution to a significant fraction of transmissions of HIV and other infectious agents has not been adopted."
Momentum toward mandating autodestruct syringes on a global scale is building. The Merck Pharmaceutical Co. recently teamed up with the Farmingdale-based Univec Inc., using their autodestruct syringes in a large child vaccine campaign in Honduras. And GlaxoSmithKline has agreed to package all of its childhood vaccines that are sold to poor countries in Univec autodestruct syringes.
"My worry is that people will find a way to get around that and you'll encourage people to get secondary quality vaccines from eastern Europe, so that they don't have to use autodestruct syringes," said Dr. Barry Bloom, dean of the Harvard School of Public Health. "If you really want to do it, there should be a WHO standard, mandated worldwide."
Advocates in WHO and in medical and humanitarian groups are calling for such a standard. The Bill and Melinda Gates Foundation and Rockefeller Foundation are examining the logistics of large-scale use.
One form of prevention is paying off, as pediatric AIDS is disappearing in wealthy countries due to the use of Nevirapine, a drug that prevents a pregnant woman's transmission of HIV to her infant. Nevirapine, manufactured by Germany's Boehringer Ingelheim, costs only 80 cents per dose, and the company has offered it free to most African nations. But few women are receiving it. In South Africa alone, 2,000 HIV-positive babies are born every day, because the drug isn't being made available to their mothers.
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