HIV OUTBREAKS AMONG CHILDREN HIGHLIGHT NEED FOR REFORM

UNCLAS SECTION 01 OF 03 ASTANA 002404 SIPDIS STATE PASS AID FOR S/GAC CLANGLEY, AID/ASIA BWALLIN AND GCOOK, AID/GH CVINCENT CDC FOR COGH DCHRISTIANSEN, CDC/GAP OKHAN E.O. 12958: N/A TAGS: PGOV PREL EAID SOCI KG TI TX UZ KZ SUBJECT: HIV OUTBREAKS AMONG CHILDREN HIGHLIGHT NEED FOR REFORM REF: ASTANA 2290 ¶1. (U) Sensitive but unclassified. Not for public Internet. ¶2. (SBU) SUMMARY: Recent outbreaks of HIV and AIDS among children in three countries of Central Asia point to dangerous and unnecessary medical procedures being performed throughout the region. A recent assessment conducted by USAID through the President's Emergency Plan for AIDS Relief (Emergency Plan, or PEPFAR) found that health providers and managers lack the knowledge, supplies, and equipment to protect their patients from acquiring infections such as HIV in the clinical setting. In partnership with the Emergency Plan, CDC has identified blood safety as another crucial need, and is working to improve those systems. USAID and CDC's programs, made possible by PEPFAR, work to address the institutional, systemic, and practical barriers to facility-based infection prevention/ injection safety and control in the region. END SUMMARY. RECENT OUTBREAKS OF HIV AND AIDS AMONG CHILDREN IN CENTRAL ASIA DRAW ATTENTION TO POOR CLINICAL PRACTICES ¶3. (SBU) Recent pediatric outbreaks of HIV provided public evidence that unsafe medical interventions have created a new risk group for HIV in Central Asia: young children receiving medical care. In 2006, an outbreak of HIV and AIDS was discovered among hospitalized children in southern Kazakhstan. Further investigation by CDC, supported by the Emergency Plan, determined that the outbreak had been caused by a combination of contaminated blood supply and unsafe -- and often unnecessary -- medical procedures. Of particular concern are the practices of reusing contaminated medical equipment and performing unnecessary blood transfusions. One child surveyed was found to have undergone over 20 transfusions during his two years of life. While cases are still being identified, currently 155 children are known to have been infected in the Kazakhstan outbreak. ¶4. (SBU) In 2007, an outbreak of HIV in southern Kyrgyzstan was discovered among children under the age of two who had been hospitalized. Investigations supported by PEPFAR determined that this outbreak was also due to contamination of the blood supply and re-use of medical instruments. To date, 110 Kyrgyz children have been identified as HIV-infected as a result of this outbreak through contact tracing conducted by local specialists. Unofficial information indicates that this is the second such outbreak in Osh in the last three years. ¶5. (SBU) On November 11, reports of a similar outbreak in Namangan, Uzbekistan were provided to the international media. This outbreak was discovered in October, and is also considered to be caused by a contaminated blood supply and unsafe medical practices. More than 40 children have been identified as HIV-infected. While this is not the first such outbreak to be documented in Uzbekistan, it is the first time that news of this type of outbreak has been reported by the media. The CDC, supported by the Emergency Plan, did an assessment in Uzbekistan in July 2008 which also highlighted the lack of infection control procedures and the practice of reusing contaminated medical equipment and performing unnecessary blood transfusions in healthcare settings. RECENT STUDY IN THE KYRGYZ REPUBLIC FINDS SIGNIFICANT NEED FOR UPGRADES AND REFORM ¶6. (SBU) USAID, in partnership with the Emergency Plan, conducted an assessment of infection prevention and control of facility-based transmission of HIV in July 2008 in Osh, Kyrgyzstan. The study found that, while centralized public health capacity to provide training and monitoring assistance on infection prevention exist, these efforts are understaffed and inadequately funded. Due to the publicity surrounding the recent outbreak in Osh, a high level of awareness of the need for infection prevention and control exists among health workers there. Unfortunately, awareness of the need for better infection control is not matched by knowledge of what to do about it. The assessment team observed several risky practices, ASTANA 00002404 002 OF 003 primarily related to improper handling of needles, disposal of medical waste, and overcrowding of patients (more than one child per cot or incubator). The assessment also found a chronic shortage of essential commodities and medical equipment, leading to reuse of contaminated equipment. ¶7. (SBU) The supervision system in Central Asia, adopted during Soviet times, emphasizes inspection and punishment rather than supportive supervision. For instance, the Ministry of Health in Kazakhstan fired dozens of health professionals as a result of the pediatric HIV outbreak discovered in that country, and 21 people were arrested and found guilty of negligence, fraud, and acceptance of bribes. (NOTE: Per reftel, on November 19, Anatoliy Dervonoy was replaced by Zhaksylyk Doskaliyev as Kazakhstan's Minister of Health. President Nazarbayev criticized the Ministry for fostering a system where doctors take bribes and sell medicine that is supposed to be free, use state funding irrationally, and do nothing to prevent maternal and child morbidity. END NOTE). Kyrgyzstan has arrested at least three health providers to date. In the aftermath of the pediatric outbreak in Osh, health workers appeared panicked and were reluctant to share information with outsiders. Very few incentives and recognition exist for good work. Kyrgyzstan is losing its trained health workers, who are migrating out of the country due to low salaries and poor morale. High rates of turnover threaten gains made in improving the quality of health services, and migration is causing acute shortages of healthcare workers, particularly in the southern region. ¶8. (SBU) The assessment report provides a long list of specific recommendations for the Kyrgyz Ministry of Health and donors to improve the environment for infection prevention and control. Recommendations range from reforms to policies and systems, to upgrades in commodities and equipment; to building the capacity of a range of health workers and better informing consumers to influence patient demand for services. INADEQUATE BLOOD SAFETY SYSTEMS AND CONSUMER DEMAND CONTRIBUTE TO HEALTHCARE-ASSOCIATED INFECTIONS ¶9. (SBU) A study supported by the World Bank and the Emergency Plan in 2008 drew attention to the serious risk of contracting HIV and other infections via blood transfusions in Central Asian countries. Findings indicate that current screening systems used on donated blood in the region are weak, often leading to a false sense of security in the blood supply, while some facilities do not test donated blood at all. The study found a 0.2% prevalence of HIV among blood that had already been screened. Through PEPFAR, CDC is providing technical assistance to blood centers in the region to improve blood safety practices. ¶10. (SBU) A high demand exists among healthcare consumers for injections, intravenous transfusions of medicines, and blood transfusions across the region. These procedures represent a substantial source of informal income for underpaid health providers, as consumers are willing to pay additional fees under the table for these services. There is little knowledge and awareness among patients and health workers about when these procedures are or are not necessary, what the risks are to the patient, and what precautions are required when administering these procedures. USAID SUPPORTS INFECTION PREVENTION AND CONTROL UNDER PEPFAR ¶11. (SBU) Throughout November, USAID, under the Emergency Plan, will be training approximately 380 health workers in southern Kyrgyzstan and Bishkek on best practices for infection prevention and control in the clinical setting. The curriculum used for these training events is based upon an updated version of the Kyrgyz national infection prevention policy, which USAID through PEPFAR will publish in Kyrgyz and Russian and make available throughout the country. Experts will conduct mentoring visits in facilities where the training sessions were conducted, in order to provide supervisory support to trained staff as they implement new techniques. ¶12. (SBU) USAID's health program seeks to improve care and decrease infections by introducing and reinforcing the concept of evidence-based medicine, or utilizing medical techniques that have been scientifically proven to be effective, only when they are ASTANA 00002404 003 OF 003 proven necessary. USAID's maternal and child health activities have introduced HIV prevention through training events and mentoring on effective perinatal standards in 50 maternity wards throughout the five Central Asian countries. Results include adoption of international standards required to prevent infection. These precautions improve injection safety, indicate judicious use of blood and blood products, and promote the use of new interventions to reduce post-partum hemorrhage and the subsequent need for blood products. ¶13. (SBU) Last year, USAID funded a study tour for ten public health professionals and a representative from Kazakhstan's Ministry of Health to travel to the U.S. to learn about HIV prevention programs, infection control regulations, and blood bank services. ¶14. (SBU) USAID is conducting a situational analysis of primary health care facilities and tuberculosis hospitals in the region, to further identify institutional and systemic barriers to infection prevention. This analysis will add to the knowledge provided by the recent assessment conducted in hospitals in Osh, and will guide future health reform activities to address infection control as a goal for financial and structural reforms. ¶15. (SBU) USAID is finalizing its health strategy in Central Asia for the period of 2009-2013, and is drafting scopes of work for specific programs. These scopes cover many areas that should have a significant impact on the root causes of unsafe medical practices and poor infection prevention, including: support for workforce planning and performance-based incentives for health workers to increase retention and encourage quality of care; improvement in commodities management to ensure adequate stocks of required supplies and equipment; the institutionalization of evidence-based medicine to discourage inappropriate medical interventions; participatory quality improvement programs to encourage self monitoring and transparent reporting; building the capacity of national organizations tasked with monitoring and promoting infection prevention; and creating centers of excellence to demonstrate, teach, and practice proper treatment procedures. During the coming months, USAID will post on the internet draft scopes of work on new health programming for public comment. MILAS