Cluster of HIV Infections Associated With Unsafe Injection Practices in a Rural Village in Cambodia

Medical injection and infusion practices among HIV-seronegative people and people living with HIV: a behavioural survey of 10 HIV testing and opportunistic infections/antiretroviral therapy sites in Cambodia

OBJECTIVES

In late 2014, an HIV outbreak occurred in rural Cambodia among villagers who received medical injections from unlicensed medical providers, justifying the need to assess medical injection practices among those who are at risk of acquiring and/or transmitting HIV. This study examined medical injection/infusion behaviours among people living with HIV (PLWH) and those who were HIV negative in Cambodia. These behaviours should be properly assessed, especially among PLWH, as their prevalence might influence a future risk of other outbreaks.

DESIGN

A cross-sectional survey was conducted in order to examine injection behaviours and estimate injection prevalence and rates by HIV status. Unsafe injections/infusions were those received from village providers who do not work at a health centre or hospital, or traditional providers at the participant's (self-injection included) or provider's home. Logistic regression was performed to examine the relationship between unsafe injection/infusion and HIV, adjusting for sex, age, education, occupation, residence location and other risk factors.

SETTING

The survey was conducted in 10 HIV testing and treatment hospitals/clinics across selected provinces in Cambodia, from February to March 2017.

PARTICIPANTS

A total number of 500 volunteers participated in the survey, 250 PLWH and 250 HIV-negative individuals.

OUTCOME MEASURES

Measures of injection prevalence and other risk behaviours were based on self-reports.

RESULTS

Both groups of participants reported similar past year's injection/infusion use, 47% (n=66) among PLWH and 54% (n=110) HIV-negative participants (p=0.24). However, 15% (n=11) of PLWH reported having received unsafe last injection compared with only 7% (n=11) of HIV-negative participants. In logistic regression, this association remained numerically positive, but was not statistically significant (adjusted OR 1.84 (95% CI: 0.71 to 4.80)).

CONCLUSIONS

The inclination for medical injections and infusions (unsafe at times) among PLWH and the general population in Cambodia was common and could possibly represent yet another opportunity for parenteral transmission outbreak.

An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan

BACKGROUND

From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, a case-control study was conducted in June 2019.

METHODS

For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression.

RESULTS

The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician [adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79]. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400).

DISCUSSION

Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.

Massive Iatrogenic Outbreak of Human Immunodeficiency Virus Type 1 in Rural Cambodia, 2014-2015

Background

In 2014-2015, 242 individuals aged 2-89 years were newly diagnosed with human immunodeficiency virus type 1 (HIV-1) in Roka, a rural commune in Cambodia. A case-control study attributed the outbreak to unsafe injections. We aimed to reconstruct the likely transmission history of the outbreak.

Methods

We assessed in 209 (86.4%) HIV-infected cases the presence of hepatitis C virus (HCV) and hepatitis B virus (HBV). We identified recent infections using antibody (Ab) avidity testing for HIV and HCV. We performed amplification, sequencing, and evolutionary phylogenetic analyses of viral strains. Geographical coordinates and parenteral exposure through medical services provided by an unlicensed healthcare practitioner were obtained from 193 cases and 1499 controls during interviews.

Results

Cases were coinfected with HCV (78.5%) and HBV (12.9%). We identified 79 (37.8%) recent (<130 days) HIV infections. Phylogeny of 202 HIV env C2V3 sequences showed a 198-sample CRF01_AE strains cluster, with time to most recent common ancestor (tMRCA) in September 2013 (95% highest posterior density, August 2012-July 2014), and a peak of 15 infections/day in September 2014. Three geospatial HIV hotspots were discernible in Roka and correlated with high exposure to the practitioner (P = .04). Fifty-nine of 153 (38.6%) tested cases showed recent (<180 days) HCV infections. Ninety HCV NS5B sequences formed 3 main clades, 1 containing 34 subtypes 1b with tMRCA in 2012, and 2 with 51 subtypes 6e and tMRCAs in 2002-2003.

Conclusions

Unsafe injections in Cambodia most likely led to an explosive iatrogenic spreading of HIV, associated with a long-standing and more genetically diverse HCV propagation.

Out-of-Pocket Household Expenditures on Medical Injections in Cambodia

BACKGROUND

Cambodia has one of the highest rates of overall medical injection usage worldwide. Therapeutic injections, which are often unnecessary, contribute to the spread of blood-borne diseases.

OBJECTIVE

This study describes injection practices and associated household expenditures in rural northwest Cambodia.

METHODS

We assessed care-seeking patterns of surveyed adult family members who sought healthcare in the previous 30 days, including location of care, medical injection use, and out-of-pocket household expenditures for treatment. A regression model was used to explore the impact of injection use on out-of-pocket household expenditures.

RESULTS

Among 480 households sampled, 298 included members who had been sick within the previous 30 days; a total of 342 episodes of care had been sought. Private providers accounted for over 66% (n = 226) of all episodes of care, with public and informal providers accounting for 20% (n = 69) and 14% (n = 47), respectively. Injections were administered in over 120 (35%) episodes of care, with 81% of injections administered by private providers. Patients who received injections incurred total out-of-pocket household expenditures that were, on average, 126,590 Cambodian Riel (KHR) (US$31.65) higher than those who did not receive injections (p < 0.01), equivalent to nearly half of the country's total annual health expenditure per capita. Receiving injections and perceived severity of illness were significantly associated with higher out-of-pocket household expenditures.

CONCLUSION

This study found high levels of medical injection use, particularly among private healthcare providers, which was significantly associated with high healthcare expenditures. Reducing the number of medical injections would not only reduce disease transmission risk but also contribute to reduced healthcare costs and greater financial protection.