[Congressional Record (Bound Edition), Volume 149 (2003), Part 16]
[Senate]
[Pages 21699-21702]
[From the U.S. 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.
  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

[[Page 21700]]

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 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.

[[Page 21701]]

  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 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

[[Page 21702]]

sentences to be handed to 1,000 men, women, and children every day 
through their inaction.

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