Editor The observation by Feachem that health systems of poor countries are dysfunctional (1) is a sad truth. Due to fear and discrimination by health care workers, it is still difficult for people with HIV to be admitted to hospitals for the treatment of common ailments like injury, fever, pneumonia, diarrhoea, delivery, etc., even after nearly two decades of the HIV epidemic. That is not to say that health workers are neglecting people with HIV. It is ironic that health workers, afraid to take care of the relatively few known HIV-positive people, are in fact taking care of many more undiagnosed HIV sufferers without taking even basic safety precautions. Nurses, laboratory technicians and phlebotomists, who are exposed daily to hollow needle injections, as well as staff who clean the used instruments, are at greater risk of occupational HIV infection than other health care workers. But safety precautions, including the proper disposal and incineration of needles and the decontamination of used instruments, are not routinely taken to protect the vulnerable "lower staff".
Similarly, the recommended practice of using only sterilized or high-level disinfected gloves and instruments, during procedures with the potential for transmission of blood-borne infections, is not routinely followed in minor medical and dental procedures. These minor procedures are more common than major ones, but instead of collectively trying to make them safe and reduce unnecessary ones, surgeons perceive themselves to be at undue risk. They advise indiscriminate preoperative HIV testing without counselling or confidentiality. They also deny necessary surgery to those who test positive. In a central hospital of Nepal during the last 3 years, the proportion of HIV tests on admitted patients performed by the surgical department was almost two-thirds of the total performed. Examples of such behaviour do little for the declining morale among health workers and it is no wonder that discrimination against people with HIV continues amongst the public. Defeating HIV-related discrimination requires that health and social services be sensitive to discrimination and act against it (2).
The modes of HIV transmission have been well defined and precautions to prevent bloodborne infections can easily be taken without compromising care of HIV sufferers. Making arrangements for these simple precautions is surprisingly difficult in developing countries. One of the major hurdles in implementing the precautions is difficulty in communication, explanation and reinforcement of these issues to health workers and managers. I have focused on displaying posters outlining safety issues at the workplace as a continuous reminder to all workers concerned, but this may achieve only limited local impact. Regular implementation of basic safety procedures would allay fears of the health care workers and, in turn, accelerate health care access to people with HIV, a key priority of UNAIDS as highlighted by Piot & Seck (2). These two issues are interlinked. Unless international experts and organizations, especially WHO, come up with clear recommendations, the situation will not change in most developing countries. With increasing concern over the possible significant role of minor health procedures in the spread of HIV (3), the need of such international recommendations has become imperative. 
Madhur Dev Bhattarai3
Conflicts of interest: none declared.
1. Feachem R. HAART the need for strategically focused investments. Bulletin of the World Health Organization, 2001;79:1152-3.
2. Piot P, Seck AMC. International response to the HIV/AIDS epidemic: planning for success. Bulletin of the World Health Organization, 2001;79:1106-12.
3. Drucker E, Alcabes PG, Marx PA. The injection century: massive unsterile injections and the emergence of human pathogens. Lancet 2001;358:1989-92.
3Consultant Physician, Department of Medicine, Bir Hospital, Post Box 3245, Kathmandu, Nepal (email: mdb@ntc.net.np).