Editorials

The rights of HIV infected healthcare workers

Until the advent of antibiotics, health care workers have always been at significant risk of serious harm from the diseases they seek to treat. Their situation has often been known to colleagues and attracted sympathy, even from the media. However infection with HIV is quite different.

In this issue, Sandy Logie, a doctor who contracted HIV while working in Africa, writes of his personal dilemma about the inability to share his problem with colleagues and others (p 1679).¹ A decade ago HIV was associated with drugs, homosexuality, and death within about four years, and we knew little about transmission in the healthcare setting. The scene has changed greatly; attitudes have not.

Respect for human rights is at the heart of the debate about HIV. In accordance with the principle of "do no harm," this debate has been biased in favour of patients, and infected healthcare workers have received little support from the profession and the media.

Britain's Department of Health has issued guidelines on managing infected healthcare workers² and on notifying patients who may have been exposed to infection.³ A management pathway is clearly laid down, and all hospital trusts and health authorities should have local arrangements in place. In particular, the name of a designated physician or occupational health practitioner should be widely available. This person should be able to give confidential advice and support to employees and students who are worried that they might have become infected. Busy clinicians are likely to evaluate their own injuries,⁴ but as there is new evidence to support the prophylatic use of zidovudine within one hour of exposure⁵ it would be wiser to share this decision with a colleague.

The healthcare worker who is HIV positive may be advised to stop performing risky procedures. Such a change of work routine itself threatens confidentiality, as does a change of duties. In some clinical disciplines it is feasible and sensible to advise the healthcare worker to continue to practise. This helps to minimise the stress associated with the diagnosis.

Should such advice be given more often? The "look back" exercises carried out in Britain have not shown transmission of HIV from healthcare workers to any patient, and generally clinicians are now more careful. Many strategies have been used to reduce the number of injuries to staff during clinical procedures, including the evolution of practical policies in infection control, which recognise that any patient may be an infection risk, and the development of equipment and routines to minimise injuries. Worldwide risk assessments have been carried out for work procedures; in Britain this is a legal requirement.⁶ This examination of work procedures has led to appreciation of the relative risks and has emphasised the need to practise safely. A significant reduction in the number of injuries has been reported,^{7 8} although nurses, and more particularly house staff,⁴ seem to be at higher risk.

The main reasons for percutaneous injuries include failing to use safety equipment properly; the patient moving unexpectedly^{8 9}; and the failure of a substantial proportion of clinical staff to apply correct precautionary measures.¹⁰ Compliance in a medical setting in the industrialised world is quite different from a Third World situation, but all healthcare workers have a duty to protect themselves and their families and friends. Educating and monitoring staff should help to reduce the incidence of these injuries.

With the knowledge that the risk of transmission of infection from healthcare workers to patients is extremely small, it is important that the British government's Expert Advisory Group on AIDS and the UK Advisory Panel review the policy of the Department of Health. A policy which supports healthcare workers is more likely to be effective than one which excludes and in effect punishes them. Any policy that could reduce the number of healthcare workers wishing to be tested will result in a pool of undiagnosed and unsupported HIV positive healthcare workers.

There is a need to take a closer look at each "risk procedure" and to review the advice given to healthcare workers. Indicating procedures that cannot be performed by healthcare workers who are known to be HIV positive is valid only if all healthcare workers carrying out those same procedures are screened.^{11 12} It is also important that the policy on "look back" exercises is re-examined. These reviews give negative messages and raise rather than allay public anxiety. Those carried out so far have provided little useful information and were expensive.

Healthcare workers who receive injuries need to have confidence that by immediately reporting the injury they will receive appropriate advice and treatment, as well as the support and encouragement to continue in practice if possible. As with any immunocompromised healthcare worker, they will be at greater risk than their patients, and strict adherence to precautions to control infection risk is essential for their own safety. In some states in America such as New York and Michigan, guidelines state that "limiting the practice of HIV infected healthcare workers is inappropriate given the extremely low risk of HIV transmission from healthcare worker to patient as well as the negative consequences of practice restrictions."^{13 14} The health professions need to use current knowledge to support those who have become infected. In allaying public fears, the rights of healthcare workers have been subsumed for too long.

Director Special Needs Clinic, Department of Sedation and Special Care Dentistry, Guy's Dental Hospital, London SE1 9RT

Peter Erridge 

1. Logie AW. "Coming out"--a personal dilemma. BMJ 1996;312:0000-0.
2. Department of Health. AIDS-HIV infected health care workers: guidance on the management of infected health care workers. London: Department of Health, 1994.
3. Department of Health. AIDS/HIV infected health care workers: practical guidance on notifying patients. London: Department of Health, 1993
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6. Management of Health and Safety at Work Regulations 1992. London: HMSO, 1992.
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12. Landesman SH. The HIV positive health professional: policy options for individuals, institutions, and states. Arch Intern Med 1991;161:655-68.
13. New York State Department of Health. Policy statement and guidelines. Health-care facilities and HIV-infected medical personnel. Albany: New York State Department of Health, 1991.
14. Michigan Department of Public Health. Michigan recommendations on HBV-infected and/or HIV-infected health-care workers. Lansing: Michigan Department of Public Health, 1992.