Unsafe Injection Practices and HIV Infection

14 March 2003


Meeting Summary

WHO/UNAIDS held a meeting March 14, 2003 to discuss the relationship of unsafe injections and HIV infection. In a recent series of articles in the International Journal of STD & AIDS (October 2002, March 2003), David Gisselquist and colleagues review evidence on the relative importance of different modes of HIV transmission in sub-Saharan Africa and conclude that unsafe health care practices, largely unsafe injections, are a major mode of HIV transmission in sub-Saharan Africa. They also indicate that the contribution of unsafe sex to HIV transmission is considerably less than has been assumed.

Meeting attendees reviewed epidemiologic evidence for transmission through unsafe injections. The meeting started off with a presentation by Dr. Gisselquist to summarize the results of their analyses on the contribution of unsafe injections and unsafe sex to HIV transmission in Africa. This was followed by a series of shorter presentations and commentaries, focusing in different ways on the plausibility of whether unsafe injections might play a much larger role in HIV transmission than traditionally thought.

The second session focused on modelling of the contributions of different modes of transmission. Presentations were given on the key input parameters for models: the incidence of unsafe injections in sub-Saharan Africa and the transmission efficiency under different circumstances. The meeting closed with general discussion and a summary of the major issues.

No consensus emerged from the conference. The prevailing view was that sexual transmission was responsible for the large majority of HIV infections in sub-Saharan Africa; Gisselquist and colleagues demurred. On two points there was universal agreement. First, that better data on the possible role of unsafe injections, and other health care practices, in HIV transmission are needed to more definitively determine their role in HIV transmission in sub-Saharan Africa. Second, that unnecessary injections should not occur and, whether in the formal or informal health sector, such injections should be safe.


Chair: Geoff Garnett (Imperial College London)

Welcome, introductions, charge for the meeting (Ties Boerma, WHO, Catherine Hankins, UNAIDS)

>>Epidemiological evidence for transmission through unsafe injections

Evidence supporting unsafe injections (David Gisselquist, private consultant)

Richard Hayes (London School of Hygiene and Tropical Medicine), Jimmy Whitworth (Medical Research Centre, Kampala, Uganda), Anne Buvé, (University of Antwerp), Geoff Garnett, Basia Zaba (London School of Hygiene and Tropical Medicine), Ties Boerma

>>Modelling approaches

The biologic plausibility of unsafe injections leading to HIV transmission (George Schmid, WHO, with contribution from Robert Heimer, Yale University School of Medicine)

The incidence of unsafe injections, Western Africa (Jules Millogo, BASICS, Washington DC)

Modeling to estimate the proportion of HIV infections related to unsafe injections, with brief review of frequency of unsafe injection practices (Yvan Hutin, WHO)

Modeling to estimate the proportion of HIV infections related to unsafe injections (John Potterat, private consultant)

Preliminary results from modelling with STDSIM (Richard Hayes)

Comments & discussion (Geoff Garnett)

>>What are the main issues and what is the way forward?

Summary of main points from the discussants and discussion (Geoff Garnett)

Response to main points (David Gisselquist)

General discussion on issues and way forward

List of Participants

Dr Sevgi Aral
Associate Director for Science
Division of STD Prevention
Centers for Disease Control & Prevention

Dr Stuart Brody
Adjunct Research Associate Professor
of Medical Psychology at the University of Tubingen

Dr Charlene Brown
Technical Advisor, VCT
Technical Leadership & Research Division
Office of HIV/AIDS
Bureau of Global Health / USAID

Dr Anne Buvé
STD/HIV Research & Intervention Unit
Institute of Tropical Medicine

Dr Geoff Garnett
Department of Infectious Disease Epidemiology
Imperial College, St. Mary's Campus

Dr David Gisselquist
Private Consultant

Dr Richard Hayes
Professor of Epidemiology & Int. Health
London School of Hygiene & Trop. Medicine

Dr. Tim Mastro
HIV/AIDS Care and Treatment
Centers for Disease Control and Prevention

Dr Jules Millogo
Immunization Technical Officer
Basics II Project

Mr John J. Potterat
Private Consultant

Dr Lone Simonsen
Staff Epidemiologist
Office of Global Affairs
National Institute of Allergy and Infectious Diseases

Dr Jimmy Whitworth
Professor, International Health
London School of Hygiene & Trop. Medicine

Dr Basia Zaba
London School of Hygiene
and Tropical Medicine

WHO/UNAIDS Secretariat

Dr Ties Boerma

Dr Cate Hankins

Dr Yvan J.F Hutin

Dr Kevin O'Reilly

Dr George Schmid

Dr Neff Walker

Dr Isabelle de Zoysa