[Congressional Record Volume 149, Number 124 (Wednesday, September 10, 2003)]
[Senate]
[Pages S11360-S11364]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
AIDS
The PRESIDING OFFICER. The Senator from Alabama.
Mr. SESSIONS. Mr. President, I ask unanimous consent to speak for 2
minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
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Mr. SESSIONS. Mr. President, in part of this bill was language that
requires the CDC to develop a plan to deal with the medical
transmission of AIDS in Africa. The science is coming in clearer and
clearer that a substantial portion of the infections in Africa result
from transmissions from blood transfusions or the reuse of needles for
injections.
In fact, we believe the World Health Organization numbers say that 10
percent are caused by it. That means as many as 300,000 infections in
Africa are, in fact, a death sentence caused by unsafe medical
practices. We need to end that. We can end that.
We have had two hearings I have conducted. It is a moral crisis. It
should not be allowed to continue. Our medical agencies, including
Health and Human Services, CDC, and particularly WHO, have been slow to
respond. My remarks go into great detail about the science behind this.
It has raised the concern of human rights groups as well as health
groups. We will continue to proceed. We will be discussing in more
depth the need for focus.
By WHO's own number, they can virtually eliminate this problem for
less than $100 million a year. We will be spending $3 billion a year
when the AIDS program in Africa is rolling. We can fund this. We can
eliminate this and 300,000 people a year being infected would be
stopped. There are even studies that show 670,000 Africans in South
Africa from the age of 2 to 14 are now infected by HIV, much of that
from unsafe health practices. It is a dilemma for us. We have to act
quickly and not delay.
As this Congress takes up the task of funding a landmark global
effort to combat HIV/AIDS, it is imperative that lawmakers consider an
aspect of this crisis that has consistently not received the prominence
it deserves.
I would like to thank Senator Specter for his help in bringing this
issue to light during our consideration of appropriations for the
Departments of Labor and HHS.
While we are all aware of many excellent programs that seek to treat
this virus or prevent its transmission, it is widely unrecognized that,
even by conservative estimates, each day 1,000 Africans who go to
hospitals, clinics, or local doctors seeking treatment come away
infected with a deadly disease.
They contract this virus through unsafe injections given with needles
and syringes that are often reused again and again, or through
contaminated transfusions with blood that is never screened for HIV,
hepatitis B, hepatitis C, or other potentially deadly diseases.
In March of this year, the Washington Times reported that Dr. David
Gisselquist and his colleague John Potterat had published an article in
the International Journal of STD & AIDS, a publication of the British
Royal Society of Medicine, that presented evidence that the reuse of
needles and syringes has played a major role in the African HIV/AIDS
epidemic.
This article challenged the conventional wisdom in the international
public health community that heterosexual contact is the primary route
of transmission for HIV in Africa and that medical transmission of the
disease did not require its foremost attention.
Dr. Gisselquist pointed to a number of pieces of evidence supporting
his conclusion that medical exposures account for a large proportion of
HIV transmission.
Dr. Gisselquist conducted an extensive review of refereed journal
articles on the epidemiology of the African HIV epidemic. A careful
analysis of the data behind these studies enabled him to identify the
following trends:
Multiple studies found HIV-infected children whose mothers test
negative for the virus. Many of these children are far too young to
have contracted HIV through sexual practices or drug use, leaving their
infections unexplained by conventional assumptions about the spread of
this disease.
It was found, however, that these children bearing the HIV virus had,
on average, received nearly twice as many injections of vaccines and
medicines than their uninfected peers, leading researchers to conclude
that there was a strong correlation between the number of injections a
child received and that child's chances of contracting HIV.
International groups involved in large-scale vaccination campaigns
have long realized that injection safety is an indispensable element of
their work. This realization followed events such as the tremendous
epidemic of hepatitis C in Egypt following a nationwide effort to
vaccinate against schistosomiasis.
This is still thought to represent ``the world's largest iatrogenic
transmission event,'' contributing to an appalling 18 percent
prevalence of the deadly hepatitis C virus in the Egyptian population.
Since the recognition that unsafe injections pose an unacceptable
risk in vaccination campaigns, international efforts now almost
universally include adequate injection safety training and supplies.
These limited efforts are commendable but more needs to be done.
To understand the proportion of the problem that remains to be
addressed, one must note the distinction between injections given for
vaccinations and therapeutic injections, or injections given for the
purpose of treating infections or other disease processes.
It has been estimated that worldwide, therapeutic injections
outnumber vaccinations by about nine to one, totaling approximately 12
billion injections administered each year in the developing world,
including the African nations of the global AIDS initiative.
Despite this fact, and the demonstrated risks associated with unsafe
injections, leaders in the field of HIV prevention have warned that
``little attention has been paid to the systematic correction of
widespread unsafe practices resulting in disease transmission through
therapeutic injections.''
There are so many tragic aspects of this problem:
Hard-working frontline doctors and nurses inadvertently contribute to
the spread of the very diseases they are struggling to treat;
The health care system in developing nations frequently does not
provide either necessary education in proper injection practices or,
for those providers who are striving to follow model practices, the
relatively inexpensive supplies necessary to succeed;
Citizens come to trusted institutions for medical treatment for
themselves, or for their children, and are unknowingly infected.
Ironically, these people do not, based on present AIDS prevention
education, have any reason to view themselves as high-risk. They have
not engaged in unsafe sex or intravenous drug use--they have merely
acted responsibly and gone to the doctor.
Subsequently, these victims go home and, again unknowingly, pass HIV
or other deadly diseases to their own families--husbands to wives,
wives to husbands, mothers to children.
In this manner, this ``hidden'' source of disease transmission
continues to fuel the epidemic, capitalizing on a large blind spot in
the current HIV prevention orthodoxy.
At the outset of the AIDS epidemic in the United States, both the
U.S. Government and the public declared that the blood supply must be
rendered absolutely safe.
The Federal Government and the public health community moved rapidly
to ensure that every singe unit of blood donated in this country is
tested for the HIV virus.
It is estimated that 25 percent of blood donated in Africa is never
tested for HIV and that up to 80 percent is never tested for hepatitis.
It is estimated by the respected group, Safe Blood for Africa, that
as a consequence of this breakdown, approximately 15 percent of the
sub-Saharan African blood supply is infected with HIV and 20 percent
with hepatitis.
The World Health Organization estimates that up to 10 percent of new
HIV cases in Africa may be due to contaminated blood transfusions.
Once again, it is clear that transfusions of contaminated blood
result in yet another ``hidden'' source of disease transmission fueling
this epidemic.
Seventy percent of the recipients of these high-risk transfusions are
women and children, making blood safety a crucial component of our
larger effort to fight HIV/AIDS in mothers and children.
This figure is linked to the high incidence in Africa of malaria,
which frequently causes severe anemia, particularly in children, and of
severe postpartum bleeding. It is important to recognize, too, that
even in the treatment of anemia related to these common conditions,
best medical practices
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would dictate that many of these transfusions are unnecessary.
This is just one more example of the potential to decrease the risk
to people of deadly infection, as well as the considerable cost of
these unnecessary transfusions through educating providers on simple
guidelines for transfusion.
This administration, and our respected majority leader, Dr. Bill
Frist, have declared that ending the mother-to-child transmission of
HIV is of the utmost importance in the overall global AIDS initiative.
One of the most startling facts about the healthcare transmission of
HIV in Africa is the fact that injection safety and blood safety have
been specifically singled out by researchers as the most cost-effective
means of preventing the spread of HIV.
A study published by the WHO in 1999 suggested that addressing the
problem of unsafe injections might well result in actual savings for
the governments and organizations financing the fight against AIDS.
These savings would be generated both by a reduction in the number of
unnecessary injections, which, amazingly, may account for a majority of
therapeutic injections actually given in the developing world, and by
avoiding the tremendous financial drain associated with the averted
infections.
In testimony before the HELP committee at a hearing I chaired in
July, one of the leading WHO researchers confirmed both his own
conclusion that ending unsafe injection practices would be eminently
cost-effective and his projection that blood safety efforts would prove
to be similarly so.
As noted previously, the World Health Organization's Department of
Blood Safety and Clinical Technology has, working with a variety of
groups, produced a strong body of research on both injection safety and
blood safety in Africa.
At my urging, the Department of Health and Human Services has
undertaken the task of reviewing all of the available data to better
define the true magnitude of health care transmission through unsafe
injections. At this very moment, the Research Triangle Institute, the
private clinical research organization awarded the contract for this
study, is working toward this goal.
The results of this study will be reviewed by an independent panel of
experts in the field, and I am pleased to note that we do anxiously
await the results of this analysis, which is due to be completed next
month.
My eagerness to see action on this problem is fueled by evidence that
there have been some real successes on the ground in Africa, in some of
the poorest nations in the world:
In Burkina Faso, where in 1995 it was estimated that injection
equipment was reused at rates ranging from 20 percent in urban areas to
an appalling 90 percent in rural regions, the answer was supply. When
adequate disposable injection equipment was available through community
pharmacies, the rate of reuse dropped 92 percent within 5 years.
At the HELP committee hearing I chaired on July 31, it was very
encouraging to hear the testimony of Dr. John Ssemakula a physician
from Uganda, who was able to describe the great strides his country has
made in cleaning up injection practices. Dr. Ssemakula was also able to
convey the plea of the dedicated men and women on the frontlines of
health care in Uganda--that they be provided with the equipment they
need to provide safe injections.
These are intelligent, well-educated, well-intentioned people and
they simply want enough syringes to provide their patients with safe
care.
I have been pleased, over the past several months, to have had the
opportunity to express my concerns to Randall Tobias, the incoming
Global AIDS Coordinator at the State Department, and to Dr. Joe
O'Neill, director of the White House Office of National AIDS policy and
the new deputy coordinator and chief medical officer in the office of
the coordinator.
I hope that these gentlemen came away with a good understanding of
the crucial importance of addressing the healthcare transmission of
HIV, and I look forward to continuing to work with the administration
and other key parties to the global AIDS effort.
One of the greatest disappointments I have encountered in my effort
to draw attention and resources to this problem has been the response
of the leadership of the World Health Organization.
That being said, groups within the World Health Organization continue
to do commendable work in the area of healthcare transmission,
including Department of Blood Safety and Clinical Technology, which has
made progress in the area of blood safety and, within this department,
the Safe Injection Global Network, which is a pioneer in the field of
injection safety.
The disconnect between the good work being done by committed people
within this organization and the determined resistance of leadership to
even acknowledging that this is a substantial problem is really
appalling.
The World Health Organization and a number of other major public
health entities responded to Dr. Gisselquist's conclusions not as an
invitation to reassess their data, but instead mounted a defensive
response that consisted of an unyielding insistence on their own,
admittedly conservative figures and a campaign to discredit Dr.
Gisselquist.
At the very World Health Organization conference where its own
researchers were presenting evidence that healthcare transmission is a
more substantial problem that prior WHO numbers would suggest, the
leadership insisted on releasing a public statement that the
organization stands by its own previous numbers--even in light of its
own latest research suggesting otherwise.
At the HELP Committee hearing I chaired on this subject in July,
Holly Burkhalter of Physicians for Human Rights joined a host of
respected witnesses in testifying that the healthcare transmission of
HIV is a problem that must be addressed within the Global AIDS
initiative. Ms. Burkhalter and her colleague Dr. Eric Friedman
subsequently authored an opinion piece that was run in the Washington
Post following the hearing that eloquently reiterated this point.
It was shocking to once again open the paper to find that the World
Health Organization again declined to lead on the issue of healthcare
transmission, an area in which its own researchers are pioneers.
Instead, they opted for a competing opinion piece minimizing the
problem and opposing the devotion of any additional resources.
As things stand at present, there is still no comprehensive USAID or
administration plan to address the healthcare transmission of HIV. I
have not been made aware of any plan to address injection safety at
all, outside the context of vaccination programs.
Through appropriations directed to USAID, the Global Fund, and the
Department of Health and Human Services, the United States Congress
represents the single greatest source of funding for the international
effort to combat HIV/AIDS. In this capacity, the Congress must require
that these funds are accompanied by a moral commitment to apply
resources wisely.
It is clear that doing so requires promptly acknowledging and
addressing the issue of the healthcare transmission of HIV.
The CDC, through its Global AIDS Program and a variety of other
efforts at home and abroad, has accumulated important experience in the
prevention of the healthcare transmission of HIV.
This agency provided leadership in ensuring the safety of the U.S.
blood supply during the early days of the HIV epidemic here,
contributing to the development of one of the world's finest and safest
blood banking systems. The CDC continues to provide expertise and
support of a multitude of international efforts to promote blood
safety.
In the area of injection safety, the CDC has strongly backed efforts
to ensure that every injection given in U.S. hospitals and clinics is a
safe injection.
Overseas, the agency has supported groups such as the WHO's Safe
Injection Global Network, which has conducted important research on
safe injection practices in the developing world and also works to
disseminate information essential to the implementation of successful
injection safety programs.
At a time when the United States is launching an unprecedented
campaign against HIV/AIDS in Africa and the Caribbean, the CDC is thus
uniquely
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positioned to provide the administration and Congress with important
guidance in launching the most effective effort possible to end the
healthcare transmission of HIV.
While there are a multitude of programs, many of them CDC-supported,
addressing various aspects of the healthcare transmission problem,
there has been an ongoing failure to launch a coordinated effort to
intervene to change conditions on the ground in the African region.
A hallmark of the President's Global AIDS plan has been a commitment
to effective coordination and application of resources. This commitment
must be extended to ensuring that we put an end, right now, to the
appalling daily toll taken by unsafe injections and contaminated blood
transfusions in Africa.
The CDC must again take the lead in moving quickly and energetically
to outline a plan to comprehensively address injection safety and blood
safety in the African nations included in the Global AIDS initiative.
This plan must reflect our intent to intervene in this problem
immediately. It must include an assessment of the status of the health
care system and existing programs in these countries, but it must also
move beyond this initial assessment stage to outline the supply and
logistical requirements that we will need to understand to move forward
with real, on-the-ground interventions.
Experts in the field of injection safety suggest that an effective
injection safety program must address not only the provision and
distribution of safe injection equipment, preferably nonreusuable
autodisable syringes, but also national-level planning, the education
of providers and the public in the appropriate and safe use of
injections, and an appropriate program for waste disposal.
Similarly, a strong blood safety program must not only provide rapid
access to accurate test kits, but also staff training, quality
assurance, and a national-level program to ensure an effective system
of donor selection, blood screening, and appropriate utilization of
blood products.
Thankfully, these things have all been done before. Moreover, they
have been done before by the Centers for Disease Control. It is time
that past lessons be applied to the problem before us today, that of
the healthcare transmission of HIV.
While we may eagerly anticipate the CDC's contribution, in the form
of a strong plan, to be submitted to Congress within 90 days, the
interim must not be marked by inaction.
This issue will be before us again soon, when the Senate considers
the Foreign Operations appropriations bill, which includes the bulk of
the administration's requested appropriations to fund the global AIDS
initiative.
I intend to ensure that at that time, the issue of the healthcare
transmission of HIV in Africa is not neglected within the greater war
on HIV/AIDS.
We have reached an important historical point in the global AIDS
epidemic, a point at which the world's leaders have stepped forward to
acknowledge the scope of the problem, and its tragedy.
I would like to offer the caution that this tragedy becomes a
travesty when the leaders in the global effort are offered clear
evidence that intervention is needed, yet continue to allow death
sentences to be handed to 1,000 men, women, and children every day
through their inaction.