Dear Ecosan community,

A while ago I posted the question in the thread above, because there was no really convincing answer (Sorry Arno) I contacted a friend who is a medical doctor specialized in HIV with the same questions. Below I have copy pasted our e-mail conversation, the summary of which is that he does not know of any research that really looked into this matter (surprise!). His opinion is that with a few weeks storage time the risk of HIV transmission would be very small.

Regards

Marijn

Follows the conversation:

Q1
……..Which, finally leads to my questions to you, a little while ago I was contacted by a person wanting to implement Ecosan in an African community where there is a high prevalence (20%) of HIV. And she wondered if this means an extra health risk. I have tried to do some on-line research, but as I don’t have access to the for instance springerlink and Elsevier-online it is hard to get detailed information.
What I have found out, from various HIS/AIDS information sites is that HIV is not excreted in urine. However, there is the question of menstrual blood. If we collect urine with the so called urine diverting toilets (toilets that separate urine and feces) some menstrual blood ends up in the urine. The question is whether that would pose a health risk, possible transmission routes that I could think of:
1.) Farmers working with the urine spill some on their body and they have a cut (most likely)
2.) By accident someone gets stored urine in their mouth (seems unlikely, but hand washing may be lacking).
3.) Virus somehow survives in soil for at least a month and is consumed with produce. (unlikely?)
I have posted this on an on-line forum on Ecosan, but no-one really came up with a definitive answer.
My guess is that this would mainly depend on dilution, there is a limited amount of virus in the urine, and on how well HIV would survive in a saline, high pH and high ammonia environment.

Do you have any insights or know of any relevant research?

Thanks a lot if you can find some time to think about this,
Kind Regards

A1
Hi Marijn

How are you? Nice to hear from you. Sorry for not responding earlier. I have been asked many different questions about the ways that HIV can be transmitted, but this may be the most unusual!! I'll try to answer your question in the best way that I can, although I
don't know whether any research that pertains to your exact question has been conducted.

I don't think transmission would very be likely. While HIV can persist for up to a month outside the body - there has to be the right conditions - large volume of blood, low temperatures, high pH. etc.
Here is a very nice summary of the data about HIV survival outside the body - www.aidsmap.com/Survival-outside-the-body/page/1321278/.

You are correct that HIV is not found in the urine and that no one has ever contracted HIV from an exposure to urine. You are also correct, however, that if there is "visible" blood in the urine than there is a theoretical risk. For example, if I see a nurse that had a urine splash to the eye during work in the hospital and the urine was non-bloody - I tell her not to worry at all. If the urine was visible bloody, then I may counsel her to take precautions to reduce her risk of HIV.

I did some searching but couldn't find any specific information about survival of HIV in high pH (9.0) or in high concentration of free ammonia. Typically the research shows that HIV does not survive at low pHs. Nonetheless, I think the risk would be extremely low in the
situation you describe due to the likely low concentration of HIV that might be present and the lack of a good way that it could be transmitted (urine falling on a cut on a farmer's hand is very low risk indeed).

Is the urine stored for any amount of time before use? I suppose if it were stored for a few weeks, then the chance any HIV was still alive would be pretty low.

I'm not sure that I gave you any good scientific info to answer your question, but I hope it helped some.

Best,

Q2
Thank you for this mail, it is helpful to have someone who knows what he is talking about to look at this question.

It is also good to hear that you think the transmission risks are probably low. Based on some web research, I felt they might be, but I am not a medical person:-).

One more small question: Do you think there may be a transmission pathway of someone handling urine with a little blood that has not been stored for more than 2 weeks) and then getting infected, because he/she did not wash their hands and eats something afterwards? And also could you think of any other transmission pathways in the ecosan scenario?

PS it depends on the project how long urine is stored before using, but I would guess 2 weeks is the minimum promoted by any organization implementing ecosan.

Last, I would like to post your opinion on our ecosan forum (www.susana.org/forum) would you agree to that?
The best option (I think) would be that I copy-paste our conversation, but leave only your first name and erase all references to your email. I would then like to introduce you as: "a medical professional from the USA".

Thanks for your time

A2
Hi Marijn
I don't think there is any chance of HIV transmission by ingesting contaminated fluids. With the possibe exception of mother to child transmission via breastfeeding, ingestion of HIV is not a recognized means of transmission. The only possible way would be if the person had some cuts or erosions in the mouth and the HIV-infected urine got into them....but again we are creating a very unlikely scenario here.

If you want to include my comments on the website as you described its fine with me.

Good luck with the project!!

Hi Marijn - interesting question, I don't have the answer either, sorry. Have you tried running your question past Chris Buckley? They seem to have done more with pathogens, viruses; and the Durban area is also a high risk area I could imagine.

Alternatively, you could look for a microbiological partner (maybe RIVM? Or a local (African) partner) and write a proposal for a study, does not have to be big. Keep it in mind, it is surely a relevant and interesting point.

Keep us posted,
Mariska.

These things require risk assessments and knowledge about relative risks. Transmission with viability from urine to open wounds is highly unlikely. I would spend more time dealing with more realistic risks like intestinal pathogens and parasites. These cause more deaths than HIV, malaria and TB combined. Add malnutrition and its associated diseases and HIV will come well down on your list.

Dear Arno,

Thank you, however as you are no doubt aware, in practice it is very hard to get people to store urine for 6 months and as a result many organizations either go for shorter storage times based on analyses of risks or try to weigh the risks based on the knowledge that people may not adhere to the storage time we promote.

It was just that I had never really considered the idea of HIV or other disease transmission through menstrual blood. Though I do remember from some (maybe somewhat older documents) that it was regarded as not a risk. What made me ask the question here is that I received a query from a person who will build toilets in a community with a 20% HIV infection rate.

I did a quick scan on the web and came across some information that seems to indicate that HIV may not be a danger, especially after some weeks storage, but I was wondering if any other people have done some research on this, considering that Ecosan is promoted in a number of countries where IV is a very mayor problem.

Some stuff I found:

www.aidsmap.com/Survival-outside-the-body/page/1321278/

www.aidsmap.com/Other-body-fluids/page/1320932/

www.internethealthlibrary.com/Health-problems/HIV.htm

The second link specifically states that no HIV was ever insulated from urine based on a trial involving 40 HIV infected people. However I do not have the original source and do not know if there were any menstruating woman as part of the trial.

Once again, has anyone done more research on this, it seems an important enough topic?

Kind regards

Marijn

The WHO guidelines (2006) on safe reuse of urine dictate a storage period of 6 months prior to reuse. Stored urine produces ammonia (urea is broken down) which is toxic to bacteria and viruses. Urine is thus a hostile environment for most viruses.

Dear all,

Recently I was asked a some questions about the safety of separated urine, that I could not answer in a way that I found satisfactory.

1.) Would there be a risk of HIV transmission if menstrual blood ends up in urine?
I know the amounts are small, but then in menstrual hygiene management the blood pathway seems to be taken quite serious. And viruses seem to be able to survive in urine for extended periods of time, is there any indiction of how long HIV could survive outside the human body, or even in urine?

2.) According to the WHO guidelines 2006, STDs are not considered a risk, because they survive very short outside the host. But the Chlamydia test these days is a urine test, which seems to indicate survival for at least some time. (Though samples are probably kept at very low temperatures).

Does anyone have any insights on these topics specifically, beyond saying that these kinds of things are the reasons for the multi-barrier approach?

Thanks

Marijn