Definition of the Prevention Area
Addressing injection safety helps prevent the medical transmission of HIV and other blood-borne pathogens to patients and health care workers. Injection safety falls under the umbrella of health systems strengthening and encompasses safe medical injection, safe phlebotomy practices, safe disposal of health care waste, and the provision of post-exposure prophylaxis (PEP) following occupational exposure to HIV.
Many countries lack the policies and guidelines necessary to support injection safety practices. Health care workers without proper training and commodities for safe injection, infection control, and health care waste disposal practices may expose patients, providers, and communities to HIV.
In many countries, the problem of unsafe injections is further compounded by patients’ and health care providers’ perceptions, often culturally based, that injections are more effective than non-injection alternatives. Often, an economic incentive exists for health care providers to provide an injection because of higher fees for injection-based treatments. Further, health care providers are often not trained in injection safety or in counseling patients on non-injection treatment alternatives. Patients’ high demand for injections and health workers’ willingness to provide them results in a high volume of medically unnecessary injections. The number of phlebotomy and injection procedures performed has increased in recent years related to the rapid scale-up of prevention, testing, and treatment services provided by local governments and by programs funded through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). These factors create a greater need for new, sterile injection equipment and safe disposal strategies for the health care waste that is generated. Commodity procurement and distribution often reveal multiple, undocumented procurement mechanisms, insufficient planning, challenges with distribution, and lack of quality standards for injection equipment.
Epidemiological Justification for the Prevention Area
The World Health Organization (WHO) is currently engaged in an exercise to estimate the global burden of unsafe injection, the results of which are expected in 2011. Currently available data from WHO date to 2000. These data estimate that of the 16 billion injections administered annually in developing and transitional countries, at least 50 percent are unnecessary and unsafe; observations conducted between 1987 and 1998 found rates of unsafe injection higher than 50 percent in numerous countries. WHO estimates from 2000 indicate that unsafe injections are responsible for 5 percent of HIV infections, 32 percent of hepatitis B virus infections, and 40 percent of hepatitis C virus infections. Other data suggest a range of estimates with both higher and lower values; WHO’s 2011 estimates are eagerly anticipated to resolve discrepant estimates and assess progress since 2000.
Over the last decade, evaluation data suggest that comprehensive injection safety programs have expanded the availability of guidelines, increased the use of new syringes and needles with every injection, improved health care waste management, and increased understanding of the importance of injection safety for patients, health care workers, and the wider community.
Core Programmatic Components
PEPFAR activities are based on the strategy recommended by WHO and the Safe Injection Global Network to reduce unsafe and unnecessary injections and limit the transmission of HIV, which has been expanded to include:
- Advocacy to make injection safety and health care waste management a priority among decision makers at the national level and health service providers at the facility level
- Building health worker capacity for safe injection through the development of preservice and in-service curricula and through strengthened systems of supportive supervision
- Behavior change communication among patients and health care workers to reduce unnecessary injections and achieve injection safety
- Advocacy for health worker safety through access to PEP and through the routine provision of the hepatitis B vaccination to all health practitioners
- Support for the procurement of necessary commodities for safe injection and health care waste management
- Support for safe and proper health care waste management practices
- Developing and updating standard, evidence-based treatment guidelines for common ailments to promote non-injection treatment alternatives.
Current Status of Implementation Experience
Since 2004, PEPFAR has supported initiatives to prevent the medical transmission of HIV in Africa and the Caribbean by implementing comprehensive injection safety programs that include the elements previously delineated. Five-year follow-up assessments in 11 of the countries awarded PEPFAR funding for injection safety indicate that progress has been made; for example, almost all the countries developed a national injection safety policy and health care waste management plan. In addition, all countries have increased ownership of and sustained their injection safety initiatives through multidisciplinary participation in injection safety committees. Follow-up assessments conducted at intervention facilities also indicate a reduction in needle stick injury as reported by health workers, attributed to improved training in core practices such as not recapping used needles and properly disposing of used needles/syringes immediately in a sharps container.
Countries have developed tools for monitoring the use of safe injection and health care waste management supplies. These tools provide accurate data on the consumption of supplies and are used at the country level to advocate for resources for commodities. Logistics managers use the data to manage commodities proactively and ensure that commodities are available at service delivery points. Countries have been introduced to single-use safe injection technologies, and many countries have transitioned to self-procurement of these commodities.
The number of health care facilities that practice proper health care waste segregation in countries with injection safety programs has increased. Capacity building efforts have enabled national and local partners to develop health care waste management plans and advocate for resources. Health care workers have been increasingly sensitized to the critical role that everyone at a health facility—not just waste handlers—can play in health care waste management.
Advocacy efforts to government ministries have been effective in bringing necessary resources to support injection safety efforts. For example, some governments now vaccinate health care workers against hepatitis B and provide personal protective equipment. Injection safety projects and their partners have trained health care workers on PEP treatment guidelines and have advocated to assure the availability of PEP to health care workers.
Phlebotomy, which poses a recognized HIV risk for health care workers, was not initially included in PEPFAR’s injection safety initiatives. Country-specific data assessing the burden of phlebotomy on HIV transmission are generally unavailable to inform development of a strategy for safe practices. While guidelines on safe phlebotomy practices were developed by WHO in 2010, work remains at the country level to assess current practices and develop a response.
Best injection safety practices developed under currently funded PEPFAR country programs could be modeled to improve injection safety in other countries. While injection safety efforts began following a vertical model, this issue is cross-cutting and there must be movement toward integration as a component of efforts to strengthen health systems.