VZCZCXRO9368
OO RUEHAG RUEHAST RUEHBI RUEHCI RUEHDA RUEHDF RUEHFL RUEHIK RUEHKW
RUEHLA RUEHLH RUEHLN RUEHLZ RUEHNEH RUEHNP RUEHPOD RUEHPW RUEHROV
RUEHSK RUEHSR RUEHVK RUEHYG
DE RUEHTA #2404/01 3401030
ZNR UUUUU ZZH
O 051030Z DEC 08
FM AMEMBASSY ASTANA
TO RUEHC/SECSTATE WASHDC IMMEDIATE 4039
INFO RUCNCIS/CIS COLLECTIVE 0897
RUCNCLS/SOUTH AND CENTRAL ASIA COLLECTIVE
RUEHZL/EUROPEAN POLITICAL COLLECTIVE
RUEHBJ/AMEMBASSY BEIJING 0299
RUEHKO/AMEMBASSY TOKYO 1004
RUEAUSA/DEPT OF HHS WASHDC
RUCPDOC/DEPT OF COMMERCE WASHDC
RUEATRS/DEPT OF TREASURY WASHDC
RUEAIIA/CIA WASHDC
RHEFAAA/DIA WASHDC
RHEHNSC/NSC WASHDC 0464
RUEKJCS/SECDEF WASHDC 0379
RUEKJCS/JOINT STAFF WASHDC
RHMFIUU/CDR USCENTCOM MACDILL AFB FL
RUEHPH/CDC ATLANTA

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