Chapter 4
Reduce the Transmission of HIV

OBJECTIVE TO REDUCE THE TRANSMISSION OF HIV BY:   ensuring safe blood transfusions; enforcing respect for universal precautions; guaranteeing the availability of free condoms.

Why is reducing HIV transmission a priority?

In most settings, HIV and other STIs spread faster where there is poverty, powerlessness and instability, all characteristics of displaced settings. In this environment, it is necessary to do everything possible to contribute to the efforts to stop and reverse the increase of new infections.

What are some risk factors for the spread of HIV in displaced settings?

STIs, including HIV infections, if not addressed or checked, may increase among displaced populations for many reasons:[32]

	Poor or destroyed health infrastructures.
	Protective supplies in health centers, such as clean needles and syringes and gloves, may not be available.
	No access to condoms.
	Peacekeeping forces, military and police, groups which may have higher rates of STIs, can facilitate the spread of HIV in refugee situations.[33]
	Women and children may be coerced into transactional sex to obtain their survival needs.
	During civil strife and flight, displaced persons, especially women and girls, are at increased risk of sexual violence, including rape.
	The disturbance of community and family life among displaced populations may disrupt social norms governing sexual behavior.
	Adolescents may begin sexual relations at an earlier age, take sexual risks, such as having sexual intercourse without using a condom, and face exploitation in the absence of traditional socio-cultural constraints.
	In forced displacement situations, populations from low-HIV-prevalence areas may mix with populations from high-prevalence areas, with the risk of increasing the HIV prevalence among the lower prevalence group.

HIV Transmission The main transmission routes of HIV are unprotected sex, infected blood and mother-to-child transmission. While the majority of infections are generally a result of unprotected sex, the proportion of transmission routes varies by region.

Enforce respect for universal precautions

Universal precautions are essential to prevent the spread of infections within health care settings. This must be emphasized during the first health coordination meeting. Under the pressure of an emergency situation, there is a possibility of lack of supplies, and due to the workload, humanitarian staff may be tempted to take shortcuts in procedures, which can jeopardize the safety of patients and staff alike. Therefore, it is essential that universal precautions are respected. In addition, very limited attention is paid to support staff such as cleaners, who are often newly recruited and may not have worked in health setting environments before.

What are universal precautions?

Universal precautions are simple infection control measures that reduce the risk of transmission of blood-borne pathogens through exposure of blood or body fluids among patients and health care workers. Under the "universal precaution" principle, blood and body fluids from all persons should be considered as infected with HIV, regardless of the known or suspected status of the person. Improving the safety of injections is an important component of universal precautions. See the WHO's Web site for further information on universal precautions.[34]

Why are universal precautions particularly important in an emergency setting?

Universal precautions are essential in any setting but in an emergency, infrastructures and supplies may be destroyed or not available. In addition, due to high work pressure or other reasons, health staff are more likely to have work-related accidents and cut corners in sterilization techniques. Therefore, infection-control measures must be enabled and enforced during crisis.

The Reality of Implementing the MISP in Chad [35] The Women's Commission conducted an assessment of the MISP among Darfuri refugees in Chad in March 2004. At the time, most humanitarian actors in Chad were not familiar with the MISP and there was no overall RH focal point and only one agency with an identified RH focal point. While several protection activities supporting the prevention of sexual violence had been implemented in some camps, the protection needs of the majority of refugees living in spontaneous refugee sites on the dangerous border areas were unmet. There were no UN protection officers, focal points or reporting mechanisms for sexual abuse and exploitation, in addition to a lack of systematic interventions to address the needs of vulnerable groups such as female-headed households and unaccompanied minors. Priority activities to prevent the transmission of HIV/AIDS in this setting were nonexistent or limited at best. One humanitarian worker remarked, "Condoms would probably melt here," and another stated, "We need to concentrate on basic activities-not complicated activities like HIV." None of the three priority interventions to prevent excess maternal and neonatal mortality and morbidity were fully established. Specific planning for comprehensive reproductive health services was not evident. Over all, this assessment demonstrated a widespread lack of awareness among humanitarian actors about the MISP and a lack of emergency preparedness by UN agencies and donors to implement the MISP in this emergency setting.

What are the minimum requirements for infection control?

	Ensure all staff (both medical and support staff) in health care settings understand universal precautions.
	Ensure clean health center environment.
	Reduce unnecessary procedures.
	Ensure facilities for frequent hand washing.
	Use protective barriers, such as disposable gloves, for all procedures involving contact with blood or other potentially infected body fluids, and protective clothing, such as waterproof gowns or aprons, masks and eye shields, where appropriate.
	Use of new, disposable injection equipment for all injections is highly recommended; sterilizable injection should only be considered if single-use equipment is not available and if the sterility can be documented with Time, Steam and Temperature indicators.[36]
	Ensure space for an incinerator and sterilization facilities.
	Clean, disinfect and sterilize medical equipment [37] using the most appropriate techniques for the setting (e.g., pressure-steam, high-level disinfection, boiling in water for at least 20 minutes or soaking in chemical solutions).
	Treat injuries at work, including thorough washing of wounds, rinsing of eye or mouth splashes and providing post-exposure therapy where warranted.
	Ensure safe handling of sharp objects, including the provision of puncture-resistant containers for sharps disposal.
	Ensure that disposal grounds are fenced and not accessible to the public. Dispose of medical waste by burning and burying sharp objects in a protected pit within the grounds of the health facility and not in the communal dump.
	Properly handle contaminated waste, including human waste and corpses.[38]

What information should health workers and support staff receive about universal precautions?

Health workers and support staff should be supervised to ensure their compliance and should receive guidelines on:

	potential risks in the environment, how to protect against those risks, and what to do in case of accidents such as needle-stick injuries, cuts or blood spattering;
	what does NOT constitute a risk;
	when it is appropriate to use protective clothing and why;
	how to avoid unnecessary injections and other procedures involving sharp objects handling and disposal.

Safe blood transfusion

Safe blood transfusion is an essential part of preventing the transmission of HIV. If conducted properly, blood transfusion can save lives and improve health. However, if used inappropriately, it carries the risk of transmission of infectious agents, such as HIV, hepatitis viruses and syphilis. Improperly screened or unscreened blood and the incorrect use of blood and blood products increase the risk of HIV to recipients. In addition, it can contribute to shortages of blood and blood products for patients who need transfusion. Therefore, decreasing unnecessary blood transfusion is critical to avoid the risks of infection. Unnecessary transfusion can be reduced by appropriate clinical use of blood, avoiding the needs for transfusion and use of alternatives to transfusion. Use the standard criteria for blood transfusions [39] as outlined by WHO.

	Reduce the need for blood transfusion by training health care workers to use volume replacement solutions where possible.
	Avoid blood transfusions as much as possible at night, when there is often insufficient light.
	When blood transfusions are implemented at camp level, develop proper systems and hold appropriate medical staff accountable for the transfusions.
	Blood transfusions should ideally be done in health facilities where laboratory facilities exist to screen donors for HIV and other infections diseases, to cross-match blood and to manage complications due to blood transfusions.
	All health workers should be trained to ensure that blood transfused in their facility and/or the blood supply in the facility to which they refer patients is safe.[40]
	Select safe donors.[41]
	Ensure that all blood for transfusion is safe by ensuring that it is screened for HIV and other blood-borne diseases.[42]
	Ensure that blood banks have sufficient supplies for screening blood.
	Provide sufficient HIV and other tests and supplies for screening blood where needed.[43]

Good practices in preventing and managing the consequences of HIV observed in Darfur [44] At a clinic in North Darfur, a medical assistant was identified who was specifically responsible for ensuring universal precautions. In North Darfur, trainings on universal precautions were held with village midwives and necessary supplies were distributed including condoms.

Guarantee the availability of free condoms

Condoms are a key method of protection for the prevention of HIV and other STIs. Although not all of the population will be knowledgeable about them, condoms should be available in accessible, private areas from the earliest days of an emergency so that anyone who is familiar with them, both the affected populations and humanitarian staff, has access to them. Sufficient supplies should be ordered immediately. (See exercise box on how to calculate the correct number of condoms to order.)

Exercise

Female condoms: Female condoms can be ordered through UNFPA (RH Kit 1, Part B. For more information, see Chapter 7). Female condoms provide women and girls with a female-initiated method of preventing HIV as well as protection from other STIs and pregnancy. This can be very important since many women and girls are unable to negotiate male condom use with their partners due to a lack of power in their relationship. Female condoms are typically more expensive and they are usually not as well known as male condoms among the population. If it is possible to secure a stable supply of female condoms, efforts could be made once a stable phase of the emergency is reached to provide information to the population on this method and provide training for women, girls and men on correct use.

Where can humanitarian staff order condoms?

There are many brands of condoms on the market. It may be useful to check with the local MOH and local NGOs that work in the family planning and HIV prevention or treatment sector, as they may also be able to help with condom procurement and may be able to do so more rapidly than the UN agencies. If an agency does not have experience in procuring condoms, contact UNFPA,[45] which procures for the whole UN system, to facilitate the purchase of bulk quantities of good-quality condoms at low cost. Condoms are also available as part of Interagency RH Kits in Kit 1, part A. (See Chapter 7 for more information on RH Kits.)

How should condoms be made available?

As well as providing condoms upon request, humanitarian staff should make sure that condoms are made visible to the displaced population and provide information that condoms are available at various locations. Condoms can be set out at health facilities as well as a range of other sites such as food distribution points, community service offices and anywhere that people congregate or come to access services or supplies. It may be a good idea to make condoms available in private locations such as latrines and to supply hotels and bars with condoms.

Designing and implementing an appropriate IEC condom distribution campaign is time- and resource-consuming and is thus not a priority intervention at the beginning of an emergency. Do NOT distribute condoms to the population, which could be offensive, or conduct a mass IEC campaign on condom distribution until all components of the MISP have been implemented, when more comprehensive HIV/AIDS and family planning programs can be carefully designed.

Good Practice

When asked by national staff why there were condoms in the toilet area, the international organization representative explained: "X agency is an international organization and wherever we work in the world we make condoms available to prevent HIV transmission in the region we are working." The staff person was satisfied with this answer and condoms slowly began to be taken from the condom basket located in the staff toilet.

MISP HIV Monitoring

Sufficient materials in place for adequate practice of universal precautions Number of condoms procured and made available Health workers knowledgeable on and practice universal precautions Indicators to monitor HIV coordination: Supplies for universal precautions: Percentage of health facilities with sufficient supplies for universal precautions, such as disposable injection materials, gloves, protective clothing and safe disposal protocols for sharp objects Safe blood transfusion: Percentage of referral level hospitals with sufficient HIV tests to screen blood and consist use of them Estimate of condom coverage: Number of condoms distributed in a specified time period Which supplies are needed or which Interagency RH Kit(s) could be ordered to address this issue?[46] Number Name Color Kit 1: Condom sub-kit (Part A + B) Red Kit 12: Blood Transfusion sub-kit Dark green

Challenges and Solutions

1) What if the health facilities do not have the capacity to screen donors for HIV?   Do not administer blood that has not been screened. Strongly advocate to UN agencies, such as WHO and UNFPA, or an NGO, such as International Committee of the Red Cross, to establish blood screening services. 2) What if the culture of the displaced population objects to condoms?   Humanitarian workers sometimes assume that the wide availability of condoms may be frowned upon by some cultures. However, it is still important to make condoms visible and available because such an assumption may not necessarily be true or may not be true for everyone in the population. There are creative ways to provide this life-saving material for those who want to protect themselves or others from HIV transmission, such as placing condoms in less public yet still accessible areas.

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NOTES

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