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HIV cluster in Cambodia linked to unsafe medical injection practices
Researchers who studied a large cluster of new HIV infections in Cambodia attributed to unsafe injection practices have recommended that national prevention strategies be expanded to monitor the risk for HIV transmission via unsafe injections.
The recommendation came after nearly 3% of the residents of one rural community in northwest Cambodia recently were diagnosed with HIV after a surge in testing prompted by fears among residents that they were at risk for exposure.
“Cambodia’s current national HIV prevalence and incidence estimates are based on models that do not include risk factors associated with unsafe injections or blood transfusion,” Mean Chhi Vun, MD, MPH, director of Cambodia’s National Center for HIV/AIDS, Dermatology and STDs (NCHADS), and colleagues wrote in MMWR. “Given the high prevalence of medical injection use in Cambodia, the contribution of medical injection overuse to Cambodia’s national HIV burden might be higher than estimated.”
The team that investigated the outbreak in the commune of Roka excluded patients with existing HIV diagnoses by reviewing data from ART sites and registers of community-based HIV/AIDS care programs. Specimens that tested positive for HIV via rapid-test kits were laboratory confirmed, and risk factors associated with infection were identified via a case-control study.
A total of 2,045 residents of Roka underwent HIV testing from November 2014 to February 2015 — a surge triggered after three members of one family tested positive for HIV and claimed they were infected by medical injections given by an unlicensed health practitioner. The family included the index patient, aged 74 years, a resident of the commune with tuberculosis who was diagnosed with HIV in November 2014.
By the end of February, NCHADS had confirmed HIV infection in 2.7% of the 8,893 residents of the commune, with most cases linked to a single strain that spread rapidly within the community. According to the NCHADS case-control study, medical injections and infusions were the most likely modes of transmission, with preliminary results showing that cases were nearly five times as likely as controls to have received an IV or intramuscular injection, and four times as likely to have received an IV infusion during the previous 6 months, Vun and colleagues wrote. Test results suggested that 30% of the infections in the Roka cluster could be classified as having occurred within 130 days before specimen collection.
The investigators noted a high demand for medical injections among adults in Cambodia — an average of 2.6 per person annually. Although the proportion of injections administered with reused equipment in the cluster is unknown, a 2013 study estimated 5% of reuse in the region in 2010. Vun and colleagues pointed to a recent HIV epidemic in Indiana as an example of the “explosive outbreak potential” of HIV in a setting where contaminated needles are shared.
A majority of the patients in the Roka outbreak were not associated with populations that are primarily driving Cambodia’s HIV epidemic, including commercial sex workers, men who have sex with men and IV drug users. Whereas the country has reduced the incidence of HIV among those populations, the Roka outbreak highlights the risk for transmission through unsafe medical injections, which has historically not been a priority of Cambodia’s national HIV prevention strategy, Vun and colleagues wrote.
“Efforts should be made to educate health care workers and communities at large on safe injection practices to reduce the demand for unnecessary medical injections and increase injection safety,” they wrote. “National HIV prevention strategies should be expanded to monitor unsafe injections as a mode of transmission. Globally, a need exists for tools to estimate HIV risk in low-prevalence countries where substantial proportions of the population are regularly exposed to unnecessary and potentially unsafe injections.” – by Gerard Gallagher
Disclosure: The researchers report no relevant financial disclosures.