Views & Reviews

Discrimination against doctors with HIV must end

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3440 (Published 16 May 2012) Cite this as: BMJ 2012;344:e3440
  1. Richard Ma, general practitioner, The Village Practice, London, and Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  1. richard.ma{at}btinternet.com

The English Department of Health has consulted on its proposals to change the management of healthcare workers who are infected with HIV. It recommends relaxing the restriction on such workers performing “exposure prone procedures,” provided that they are taking combination antiretroviral therapy, they are regularly reviewed by HIV and occupational health doctors, and their plasma viral load is consistently suppressed to undetectable levels.

This recommendation follows the initial suggestion by the health departments’ expert advisory group on AIDS (EAGA) in 2007 that restrictions on dentists with HIV be reviewed. A working group that included EAGA, the Health Protection Agency’s advisory panel for healthcare workers infected with bloodborne viruses, and the health departments’ advisory group on hepatitis was established to review national guidance on the management of healthcare workers infected with HIV, hepatitis B, or hepatitis C.

The UK has one of the strictest regulations governing HIV infected healthcare workers in the world; only Australia, Ireland, Italy, and Malta take a similar stance. The proposed change allows healthcare workers to perform all types of exposure prone procedure, such as hysterectomy and open heart surgery.

The new guidance takes into account the small number of reported incidences of HIV transmission from healthcare workers to patients worldwide: four reports involve four healthcare workers and nine infected patients. Despite over 30 years of review between 1988 and 2008 and over 10 000 patients tested, there have been no cases of HIV transmission from healthcare workers to patients in the UK. The risk of HIV transmission is low for exposure prone procedures and even lower for less invasive procedures; current risk estimates are between 1 in 1 672 000 and 1 in 4 680 000—the second estimate being similar to the risk of being killed by lightning. This risk would be reduced further with treatment with combination antiretroviral therapy.

The Department of Health uses current evidence to balance patient safety with the rights of HIV infected healthcare workers. However, this recommendation is long overdue. HIV is covered by the Equality Act 2010 and is classed as a disability. Because of the demographics of risk groups, people with HIV already have to deal with prejudice and discrimination. The current guidance dates from 2005 and is unnecessarily risk averse: it sends out the wrong signals to the public about the risk of infection from infected healthcare workers and perpetuates lawful discrimination of people with HIV behind a smokescreen of “patient safety.”

Despite the low risks, public perception of this proposal must not be underestimated. A glance at the online comments on the websites of the Daily Telegraph and Daily Mail in response to this proposal suggested much public hysteria and fear about the risks of HIV transmission. Some people did not want the risk no matter how small; some preferred to exercise informed choice by having healthcare workers declare their serostatus before a procedure; others went further to suggest that HIV positive healthcare workers should wear badges so that they could be “identified”; and one even suggested the UK should have a “list” of HIV positive healthcare workers like a “sex-offenders’ register” so that “their activities could be monitored.” Views regarding healthcare workers infected with HIV as “irresponsible” were common; one even compared an HIV positive worker doing an operation to Typhoid Mary doing the cooking. Some justify that current restrictions must be working because no cases have been detected in the UK; if that were true, there would be many more than four reports of transmission of HIV from infected and untreated healthcare workers worldwide from countries without such restrictions.

The General Medical Council guidance on serious communicable diseases gives advice on the responsibilities of healthcare workers infected with a bloodborne virus such as HIV. Workers must seek advice and treatment, in this case jointly between an HIV physician and occupational health physician. The new recommendations would make this process more robust. Infected healthcare workers who do not adhere to these recommendations would put their careers at risk.

There are no reliable data on the prevalence of HIV infected healthcare workers, but by extrapolating the prevalence of HIV in the general population to healthcare workers, the tripartite working group estimated there could be 110 people affected. This could be an underestimate as according to the Health Protection Agency, one in four people in the UK with HIV are undiagnosed.

The objective of policy is to reduce the undiagnosed prevalence of HIV, including among healthcare workers. This new recommendation might help previously undiagnosed healthcare workers to come forward to be tested and managed appropriately and may help to improve society’s attitudes to people with HIV.

Notes

Cite this as: BMJ 2012;344:e3440

Footnotes

  • Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares no support from any organisation for the submitted work and no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; RM was given the remit to put sexual and reproductive health on political and clinical agenda for the London Sexual Health Programme, NHS London.

  • See www.dh.gov.uk/health/2011/12/hiv-consultation

  • Provenance and peer review: Not commissioned; not externally peer reviewed.