Injection Safety

Photo of a health worker holding a syringe
World Health Organization (WHO)


Of the 16 billion medical injections given annually worldwide, according to World Health Organization estimates, too many are unnecessary and unsafe. In fact, medical injections are the most common health care procedure worldwide. When necessary and performed correctly, medical injections and related procedures, such as blood-drawing; intravenous procedures; use of multidose vials; etc., can save lives. However, if performed incorrectly, medical injections and related procedures can transmit harmful infectious disease pathogens, including HIV. The risk of spreading HIV and other blood-borne pathogens (such as Hepatitis B and C) in this manner can be reduced drastically by lowering the number of unsafe and unnecessary injections. Injection safety is fundamental to a strong health system, and it is vital to incorporate in programs such as AIDS care and treatment, preventing mother-to-child transmission, testing and counseling, safe blood, laboratories and medical male circumcision. Safe medical injection practices protect not only patients but also local community members and health care workers who are routinely exposed to needles and other medical sharps.

Unsafe injections may result when:

  • Injections are given with used syringes or needles that are not sterile.
  • Poor injection technique is used, such as recapping used needles, using contaminated multidose vials or diluents or using inappropriate injection equipment.
  • Needles, syringes and lancets, known as sharps, are improperly discarded.

Unnecessary injections examples:

  • An injection is given instead of a medically equivalent, accepted and available alternative.
  • An injection is given when not medically indicated.


In support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. Agency for International Development (USAID) supports programs to make medical injections and related procedures safer and to foster safe waste management. From 2004 to 2009, USAID supported large, comprehensive safe injection programs in six sub-Saharan African countries (Ethiopia, Mozambique, Namibia, Nigeria, Uganda and Zambia) as well as in Guyana. Comprehensive programs include improving basic safety of therapeutic injections, infection prevention and control, standard precautions, hand hygiene, safe management of sharps, other infectious waste and blood-drawing, supporting standard treatment guidelines to avoid unnecessary injections, improving postexposure prophylaxis after sharps injuries, as well as promoting Hepatitis B vaccinations. These programs also included training and capacity building, policy advocacy, quality improvement, performance metrics, behavior change communications, strengthening safe injection commodity procurement and management (e.g., for reuse-prevention syringes, safety boxes and personal protective equipment for waste handlers) and reducing demand for injections.

Photo of a child getting an injection

These centrally-supported, focused injection safety programs were broadly successful in improving the quality of necessary injections, reducing unnecessary injections, improving patient and health provider safety and ensuring safer management of sharps and other infectious waste. After the major infusion of PEPFAR central support ended in 2009, in order to sustain injection safety standards and programs, field missions in Ethiopia, Namibia, Nigeria and Uganda prioritized maintaining focused, ongoing injection safety programs, notably within AIDS treatment programs. These programs incorporated activities such as improving safety of therapeutic injections, safe management of sharps and other infectious waste, increasing hand hygiene and more. In some cases, field missions have had to put all injection safety programs into AIDS treatment without the previously available specific focus to ensure quality and consistency. Success has been variable, and substantial injection safety programs remain necessary in virtually all PEPFAR-supported countries.


In addition to countries such as Nigeria and Uganda that continued focused PEPFAR injection safety programs, USAID, with central resources, initiated modest injection safety programs based on needs assessments in several countries that did not benefit from earlier PEPFAR support, most recently Swaziland.

The AIDSTAR-One project

Through the AIDSTAR-One project, USAID Nigeria continued an outstanding, innovative and comprehensive injection safety/waste management program, including training/capacity building and advocacy, to support continued expansion of overall HIV activities in Nigeria, partnering with the National Primary Healthcare Development Agency. AIDSTAR-One fostered the procurement of safe injection commodities, such as reuse-prevention syringes and safety boxes, and pioneered safe blood-drawing practices. In partnering with Supply Chain Management Systems and the Government of Nigeria, AIDSTAR-One has also carried out a highly innovative program to safely dispose of 70 tons of expired ARV drugs, laboratory chemicals and HIV test kits in such a way that the residue was converted into bricks [PDF, 280KB].

A waste handler loads a safety box with infectious sharps waste into an incinerator for final disposal.
A waste handler loads a safety box with infectious sharps waste into an incinerator for final disposal.

The Third National Strategic Plan and Medical Waste Disposal

Also through the AIDSTAR-One project, USAID Uganda supported various initiatives to improve management of infectious and other sharps waste, for example, through recycling plastics waste in central Uganda, training health workers in successful waste management and fostering a sustainable health care waste management program in the third National Strategic Plan. In addition, through AIDSTAR-One, USAID pioneered a public-private partnership with Green Label Services Limited, a private waste handling service provider, and the Ministry of Health that will cost-effectively dispose of medical waste in all health facilities in a large portion of eastern Uganda. The program has expanded from 6 to at least 16 districts.

Applying Science to Strengthen and Improve Systems (ASSIST Project)

With PEPFAR central support, USAID, initially through the Health Care Improvement Project, and subsequently through the follow-on ASSIST Project, successfully improved injection safety and waste management practices in Sindh, Pakistan, demonstrating impressive results in a short time on a wide range of measures. The Health Care Improvement and ASSIST projects have also led to marked improvements in injection safety and waste management in Mali's Sikasso and Bamaki regions.

The ASSIST Project in Swaziland has two parts: (1) Carry out a baseline needs assessment, then work with the Ministry of Health in 20 facilities to improve infection safety practices using quality- and collaborative-improvement approaches, specifically with the aim to (a) reduce unsafe injection practices, (b) implement proper waste management practices, and (c) increase health worker safety; (2) Evaluate the impact and efficiency of improving injection safety practices on health worker engagement and attitudes toward caring for PLHIV.


Last updated: January 25, 2016

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