The recent disclosure of at least 46 people becoming infected with HIV in the Unnao tehsil of Uttar Pradesh (UP), allegedly after a quack used contaminated syringes to administer injections, has triggered shock-waves in medical circles and sent the government into the knee-jerk mode.
HIV happens to get larger public attention than the more than 20 other infections that are transmitted through unhygienic syringes or needles, and some of them are highly transmissible compared to HIV. For instance, hepatitis C Virus-HCV is 10 times and hepatitis B Virus – HBV is 100 times more transmissible than HIV. Nevertheless, a thorough investigation is needed in this episode involving different agencies engaged in health at the Centre and state levels and professional organisations such as the AIDS Society of India (ASI). There have been instances of quacks being involved in organ trade, abortions, surgeries, using spurious medicines and making false claims.
Even though HIV infections are at present relatively low in Uttar Pradesh, the recent data released by the National AIDS Control Organisation (NACO) reveals that HIV incidence (new infection rates) are the highest in UP, Bihar, Rajasthan and Gujarat, whereas the erstwhile high HIV prone states of Maharashtra, Karnataka and Tamil Nadu have taken a backseat! Unnao-like incidents are not only shocking but a formidable blot on the reputation of India’s National AIDS Control Programme (NACP).
By far the least possibility of HIV infection in India has been through hospital practices and blood transfusion modes of transmissions and both depend solely upon the efficiency of the national programmes. Efficiency of HIV prevention through sexual transmission mainly depends on individuals and the government cannot dictate any of what happens in bed-rooms!
People’s Health Organisation (India) (PHO), which has been championing the fight against AIDS since 1985 and has fought legal battles for blood and hospital safety since 1989 single-handedly, is concerned with the casual approach shown by official agencies and the much-touted National Health Mission. The easiest factor in HIV prevention and control, namely, blood safety, took more than 12 years to implement in India after the first HIV infections were detected and 9 years after PHO filed public interest litigation (PIL) in the Bombay High Court in 1989, when even the term ‘PIL’ was non-existent in legal jargon! Blood safety has contributed significantly to HIV prevention. HIV transmission through blood among the total HIV cases in India is down to less than 2% now, from 10% before 1998. State AIDS Control Societies (SACs) are usually saddled with stock-outs of medicines and testing kits at the anti-retroviral treatment (ART) centres, shortage of and dis-interested ART officers. Project directors of SACs often hold dual charges with a much reduced focus on SACs.
The Unnao episode reminds us of an incident of accidental HIV infection contracted by 13 German nationals in October 1985 which resulted in the German health minister’s resignation. In France, there was two months’ delay by the health ministry in starting HIV tests in blood banks, awaiting the parliament’s assent, after the tests were commercially available in France. Another similar incident in France in July 1985 resulted in the prosecution of the then French health minister later in 1999, hitting international headlines, where the commercialization of HIV tests was delayed by two months after they were found successful in laboratory research. However a massive incident of this nature amounting to genocide may be ignored, because it pertains to India, speaking volumes on the double standards of our policy makers and planners.
Injections may not only bring a variety of infections through contaminated needles/syringes but are also often responsible for causing anti-microbial resistance, as most practitioners use inadequate doses of antibiotics. There is a huge buffer margin between the actual buying rate and the minimum retail price (MRP) of injections. Quacks as well as licensed medical practitioners work on the dictum: ‘the pricks work better than the pills' and ‘pricks bring more money than pills.’ They also know how to play on people’s psyche and fleece them, true to the maxim ‘Mareez paisa deta hai, ya to khat pe ya fir murda-ghat pe’ (People pay: if not on the hospital bed, then on the funeral pyre). Patients feel harassed and get commercially exploited, in addition to exposing themselves or others to several injection or transfusion-transmitted infections, most of which are not screened before transfusion. In fact, the hepatitis B negative people should receive hepatitis B vaccines; which are inexpensive and even our VVIPs which have recently succumbed to HBV infection (like the Union minister Vilasrao Deshmukh). Those who have gone through liver transplants as a consequence of HBV infection could have been spared and saved.
The same is true of blood transfusions. Nearly 40% of blood is used for unwanted / un-indicated single-bottle transfusions. Hence in the blood business there was a lot of abuse of blood. After PHO’s PIL in 1989, the Maharashtra government had shut down several private blood banks in Mumbai and had suspended the manufacture of all blood products in India when 70% of them were found to be HIV tainted due to contamination in the manufacturing processes. The blood sellers are also potential organ (kidney, eye, skin etc.) sellers. Major kidney trade between India, the Middle East and Europe, with the fullest involvement of medical establishments, were also exposed by PHO. In 1998, the Supreme Court of India had passed an order to ensure blood safety that resulted in operation clean-up of the blood banks by NACO by equipping the centres and training the staff. There are nearly 22 blood borne infections that are transmitted through contaminated blood, of which only 5 are screened routinely – HIV, hepatitis B and C, syphilis and malaria. And even after knowing the hepatitis B status, people are not told to be vaccinated against HBV, the cost of which is very low, less than Rs100/-. ASI offers to send a high-level experts delegation to brief the UP government officials and experts on the ground, on boosting safe injection practices, blood safety, HIV programmes so that UP can progress towards the National Health Policy (NHP) targets of the Union government as well as its UP state health policy.
ASI recommendations on injection safety: With the longest experience in HIV/AIDS in India and adequate understanding on the demand for injection practices and knowing fully the limitations, the ASI devised the following multi-pronged strategy for injection safety to halt the spread of HIV and other blood-borne infections:
a) Appeal to doctors and hospitals: To use injections only when they must, avoid injections where oral medications or local applications can help, to use intravenous fluids (saline/ glucose) judiciously - only when it is really indicated, always use disposable syringes/needles, use burners and needle cutters to destroy the used needles and dispose of syringes properly as they are a bio-hazard. Avoid commercialisation of injections and follow the highest standards of medical ethics.
b) Appeal to the government: To strictly ban the quacks, making quackery a severely punishable crime; to make injection/needle safety as a pre-requisite for every clinic or hospital; to provide guidelines and publicity material to blood banks, clinics, and hospitals on injection safety and universal precautions; to urgently review and survey Unnao like instances and to rehabilitate victims.
c) Appeal to the people: To increase habits on voluntarily declining suggestions for injections/ IV fluids and instead use oral, local applications, and suppositories; to tactfully question doctors' prescription for Injections and IV fluids or blood transfusions - for their own safety. Often patients insist on injections and this habit should be discarded.