The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.However injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region. IDU is increasingly common among young adults in sub-Saharan Africa and is associated with high risk sex, thus linking IDU to the already well established and concentrated generalized HIV epidemics in the region. Demand reduction programs based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services.Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm reduction programs e.g. needle exchange programs are almost non-existent in the region. Among injection drug users and among drug treatment patients in Africa, knowledge that needle sharing and syringe reuse transmit HIV is still very limited, in contrast with the more successfully instilled knowledge that HIV is transmitted sexually. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia, and North America.

Background:Unsafe medical injections are a prevalent risk factor for viral hepatitis and HIV in India.Objectives:This review undertakes a cost–benefit assessment of the auto-disable syringe, now being introduced to prevent the spread of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV).Materials and Methods:The World Health Organization methods for modeling the global burden of disease from unsafe medical injections are reproduced, correcting for the concentrated structure of the HIV epidemic in India. A systematic review of risk factor analyses in India that investigate injection risks is used in the uncertainty analysis.Results:The median population attributable fraction for hepatitis B carriage associated with recent injections is 46%, the median fraction of hepatitis C infections attributed to unsafe medical injections is 38%, and the median fraction of incident HIV infections attributed to medical injections is 12% in India. The modeled incidence of blood-borne viruses suggests that introducing the auto-disable syringe will impose an incremental cost of $46–48 per disability adjusted life year (DALY) averted. The epidemiological evidence suggests that the incremental cost of introducing the auto-disable syringe for all medical injections is between $39 and $79 per DALY averted.Conclusions:The auto-disable syringe is a cost-effective alternative to the reuse of syringes in a country with low prevalence of blood-borne viruses.

BackgroundUnsafe reuse of injection equipment in hospitals is an on-going threat to patient safety in many parts of Africa. The extent of this problem is difficult to measure. Standard WHO injection safety assessment protocols used in the 2003 national injection safety assessment in Cameroon are problematic because health workers often behave differently under the observation of visitors. The main objective of this study is to assess the extent of unsafe injection equipment reuse and potential for blood-borne virus transmission in Cameroon. This can be done by probing for misconceptions about injection safety that explain reuse without sterilization. These misconceptions concern useless precautions against cross-contamination, i.e. "indirect reuse" of injection equipment. To investigate whether a shortage of supply explains unsafe reuse, we compared our survey data against records of purchases.MethodsAll health workers at public hospitals in two health districts in the Northwest Province of Cameroon were interviewed about their own injection practices. Injection equipment supply purchase records documented for January to December 2009 were compared with self-reported rates of syringe reuse. The number of HIV, HBV and HCV infections that result from unsafe medical injections in these health districts is estimated from the frequency of unsafe reuse, the number of injections performed, the probability that reused injection equipment had just been used on an infected patient, the size of the susceptible population, and the transmission efficiency of each virus in an injection.ResultsInjection equipment reuse occurs commonly in the Northwest Province of Cameroon, practiced by 44% of health workers at public hospitals. Self-reported rates of syringe reuse only partly explained by records on injection equipment supplied to these hospitals, showing a shortage of syringes where syringes are reused. Injection safety interventions could prevent an estimated 14-336 HIV infections, 248-661 HBV infections and 7-114 HCV infections each year in these health districts.ConclusionsInjection safety assessments that probe for indirect reuse may be more effective than observational assessments. The autodisable syringe may be an appropriate solution to injection safety problems in some hospitals in Cameroon. Advocacy for injection safety interventions should be a public health priority.

This review considers whether HIV prevalence data on children in sub-Saharan Africa support the hypothesis that blood exposures account for a large proportion of HIV infections in Africa. Data from a systematic search on HIV-infected children support two analyses. In 25 studies where the mothers' HIV status was not matched with data on each child (excluding non-representative samples of children), the observed prevalence in children in 20 studies was greater than expected from vertical transmission. The population-weighted difference - 1.3% - was approximately one-third of observed prevalence in children. In 32 studies that match HIV-positive children with HIV-negative mothers, 406 discordant mother-child pairs were identified, and in studies identifying at least five non-vertical infections in children, 17.5% of HIV-positive children had HIV-negative mothers. In discussing an important role for unsafe health care in exceptionally rapid HIV transmission in Africa, leading AIDS researchers cite low HIV prevalence in children not yet sexually active. The assumption that childhood HIV prevalence would increase with age in children, if injections transmitted HIV is shown to be erroneous; it fails to account for early mortality in HIV-positive children. Evidence of child-to-child HIV transmission supports the theory that nosocomial infections are important to the AIDS pandemic, and procedures more prevalent than blood transfusions, such as injections, are likely involved.

A mass action model developed by the World Health Organization (WHO) estimates that the re-use of contaminated syringes for medical care accounted for 2.5% of HIV infections in sub-Saharan Africa in 2000. The WHO's model applies the population prevalence of HIV infection rather than the clinical prevalence to calculate patients' frequency of exposure to contaminated injections. This approach underestimates iatrogenic exposure risks when progression to advanced HIV disease is widespread. This sensitivity analysis applies the clinical prevalence of HIV to the model and re-evaluates the transmission efficiency of HIV in injections. These adjustments show that no less than 12-17%, and up to 34-47%, of new HIV infections in sub-Saharan Africa may be attributed to medical injections. The present estimates undermine persistent claims that injection safety improvements would have only a minor impact on HIV incidence in Africa.