Trial Scrutinizes Infant HIV Outbreak in Kazakhstan

Aliya Masaurova holds her 22-month-old, HIV-infected son Baurzhan. i i

hide captionAliya Masaurova holds her 22-month-old, HIV-infected son Baurzhan. The boy was infected after being treated for pneumonia at a hospital in Shymkent, Kazakhstan.

Ivan Watson, NPR
Aliya Masaurova holds her 22-month-old, HIV-infected son Baurzhan.

Aliya Masaurova holds her 22-month-old, HIV-infected son Baurzhan. The boy was infected after being treated for pneumonia at a hospital in Shymkent, Kazakhstan.

Ivan Watson, NPR
Masaurova holds son Baurzhan on her lap, while twin sister Aruzhan sits in a chair to the left. i i

hide captionMasaurova holds Baurzhan on her lap, while twin sister Aruzhan, who is not infected with HIV, sits in a chair to the left. Masaurova and her husband started a foundation that has raised more than $1 million to help the mostly poor, rural families of other infants infected after hospital stays.

Ivan Watson, NPR
Masaurova holds son Baurzhan on her lap, while twin sister Aruzhan sits in a chair to the left.

Masaurova holds Baurzhan on her lap, while twin sister Aruzhan, who is not infected with HIV, sits in a chair to the left. Masaurova and her husband started a foundation that has raised more than $1 million to help the mostly poor, rural families of other infants infected after hospital stays.

Ivan Watson, NPR
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Lindsay Mangum, NPR
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Lindsay Mangum, NPR
Selma Orazova holds her HIV-infected grandson, Sayat.

hide captionSelma Orazova holds her HIV-infected grandson, Sayat. Sayat's father abandoned his newborn son and 22-year-old wife when Sayat tested positive for HIV after being treated in a local hospital for pneumonia.

Ivan Watson, NPR

When 22-month-old Baurzhan Alsiidov tumbles out of his chair and starts crying, his twin sister Aruzhan immediately breaks into tears of sympathy.

"They do everything together: Cry together, laugh together," says their father, Kanat, as he and his wife, Aliya Masaurova, try to calm the wailing children.

Baurzhan is a little bigger; Aruzhan is more talkative.

But there is an even bigger difference between the twins. Behind little Baurzhan's ears, there are two unmistakable lumps: swollen lymph nodes.

Last summer, Baurzhan tested positive for HIV.

Baurzhan is one of at least 95 children to have tested positive for HIV in southern Kazakhstan since last summer.

Neither Aruzhan nor the children's parents have the virus. Baurzhan's father thinks his son was infected last winter, while he was being treated for pneumonia at a local hospital in the city of Shymkent, about 1,000 miles south of Astana, the capital.

Now, 21 health-care workers in Shymkent are standing trial on charges of negligence and corruption. And the impact of the story reaches beyond Kazakhstan's border: The U.S. State Department says at least one American couple adopted a child from southern Kazakhstan, without prior knowledge that the infant was infected with HIV.

"This is a tragedy for everyone involved," says a State Department official, speaking on condition of anonymity.

Health-Care System on Trial

The legal battle, which began in January and is expected to take several months, appears tilted towards the defendants, who face a maximum of five years in prison if found guilty.

The health workers deny all charges.

"These people are very upset, they are suffering from this tragedy," Dr. Gurjaman Kylyshbekova, the deputy director of Children's Regional Hospital Number 6, told the judge in March. "That's why what happened to them in the hospital, they are interpreting it in their own way. I think there have been some exaggerations. I don't think such bad things happened."

The senior state prosecutor is clearly outclassed by a team of a dozen highly paid defense attorneys. They frequently raise objections, while the prosecutor often fumbles for words.

The families of the HIV-infected children are mostly poor farmers from the countryside. Among the accused is the former head of the region's health department, who is also the sister of one of Kazakhstan's most powerful politicians.

Often it is the judge, a stern man dressed in a purple fez and robes, who asks defendants the harshest questions.

"Was it normal for the head of the recovery ward to accept presents from the mother of a patient in her office?" he asked, after hearing that one family gave a doctor a suitcase full of tableware. "Is this your office or your warehouse?"

Investigations Point to Blood, Transfusions

After the rash of infant HIV cases was first detected last summer, the government of Kazakhstan asked the Atlanta-based Centers for Disease Control and Prevention to investigate.

"Immediately we identified the main issue was blood transfusion," says Michael Favorov, director of the CDC's Central Asia office in Almaty, Kazakhstan's largest city.

The CDC report concluded that the virus was likely spread through several hospitals in Shymkent by the repeated use of unsanitary medical equipment and the "excessive, unsafe use of blood and blood products."

Favorov notes the example of an 8-month-old child who received 24 blood transfusions to "boost the immunity," according to the hospital.

Favorov says there was no medical evidence to justify those transfusions. Their widespread use is due in part to the local belief that blood is a cure-all solution. But he also notes that there is a financial incentive to give patients blood.

"We call it a black market of blood," he explains. "The blood is a product ... You have a situation [where there] might be income generation through unnecessary blood transfusions."

In Kazakhstan, hospitals are not supposed to charge patients for supplies such as medicine and blood products. But families of the infected children say they saw one hospital worker selling blood in the halls of a Shymkent hospital.

Most Cases Occurred at a Single Hospital

More than two-thirds of the children infected, including Baurzhan Alsiidov, were treated at Children's Regional Hospital Number 6. During a recent visit on a gray, freezing day, parents and children stood in the hallways of this crumbling concrete building, waiting to see their doctors.

This is where Selma Orazova, a widow, brought her grandson Sayat when he came down with pneumonia in January 2006.

The hospital staff told Orazova that Sayat needed a blood transfusion in order to be cured.

"In the hall outside the intensive care ward, we were all asking, 'Why do they need blood? Why? Why? Why?'" Orazaova says. "But I stayed silent because the child needed proper care. I didn't want to argue with the doctor."

Orazova still has the receipt a doctor gave her after she paid the equivalent of $22 for a blood transfusion for her grandson.

Several months after his treatment, Sayat tested positive for HIV. The baby's father promptly abandoned his 22-year-old wife and newborn son, leaving them at Orazova's house.

"Even I was afraid at first to hold the baby in my arms," Orazova says. "I thought I could get sick just by touching him."

Today, Orazova grips Sayat tightly in her arms and offers the chubby boy chocolates. But living conditions for the family are difficult. After being ostracized by her neighbors, Orazova, her daughter and the 16-month-old baby have moved to a university dormitory, where they live with Orazova's teenage son in a single room and share a bathroom and kitchen with their neighbors. The family is keeping Sayat's illness secret from their neighbors.

"If you ask me, we shouldn't interrogate these doctors," Orazova says. "We should line them up and shoot them."

Other Cases Link Hospitals, HIV Infections

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Lindsay Mangum, NPR
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Lindsay Mangum, NPR

Kazakhstan is not the first country where large numbers of children have been infected with HIV at hospitals.

In Romania, some 10,000 children tested positive for HIV in the early 1990s. A CDC study in the port city of Constanta found 57 percent of a group of 1,086 HIV-infected children, many of them orphans, were infected through multiple therapeutic injections and the improper use of syringes and needles.

"This outbreak demonstrates the serious potential for HIV transmission in medical facilities that intensively and improperly use parenteral [injection] therapy and have poor sterilization technique," the CDC report concluded.

In Libya in 1998, more than 400 children were found to have contracted HIV the town of Benghazi. In this politically charged case, the Libyan government accused five Bulgarian nurses and a Palestinian physician, of deliberately infecting the children. The six foreign health-care workers have been sentenced to death after a second trial; they are awaiting another appeal.

A subsequent investigation by led by Luc Montaignier, president of the World Foundation for AIDS Research and Prevention, concluded that the virus was spread in a Benghzai hospital through "certain incorrect practices used by the medical and nursing staff," during a period prior to the arrival of the foreign health workers in Libya.

The report concluded: "A large introduction of invasive procedures, the shortage of disposable materials leading to the re-use of injection materials, are all possible reasons which may explain this massive nosocomial [hospital-acquired] infection."

"It's a very interesting question why it's happening so massively with kids," says Nina Ferencic, an HIV/AIDS expert with the United Nations Children's Fund in Geneva. "Whatever it is, it's wrong."

The CDC's Central Asia director Michael Favorov has a theory for why children are particularly vulnerable to hospital-acquired HIV infections.

"They are young and cannot speak up for themselves when medical staff are inserting used/dirty/infected/contaminated catheters or any other medical instruments," he explained in an e-mail.

"For example, if an adult saw a doctor use a needle or catheter that was not prepackaged and clean the adult would refuse the injection but children do not know the difference."

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