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AIDS/HIV Infected Health Care Workers: Guidance on the Management of Infected Health Care Workers and Patient Notification
KEY POINTS AND RECOMMENDATIONS
Management of infected health care workers
1. These guidelines apply to all health care workers in the NHS and private sectors, including visiting health care workers and students.
(Paragraph 1.1)
2. All health care workers are under ethical and legal duties to protect the health and safety of their patients. They also have a right to expect that their confidentiality will be respected and protected.
(Paragraph 1.4)
3. Provided appropriate infection control precautions are adhered to scrupulously, the majority of procedures in the health care setting pose no risk of transmission of the human immunodeficiency virus (HIV) from an infected health care worker to a patient.
(Paragraph 1.5)
4. The circumstances in which HIV could be transmitted from a health care worker to a patient are limited to exposure prone procedures in which injury to the health care worker could result in the worker's blood contaminating the patient's open tissues ("bleed-back"). HIV infected health care workers must not perform any exposure prone procedures.
(Paragraphs 1.6 and 3.4)
5. The Expert Advisory Group on AIDS recommends that, as far as is practicable, patients should only be notified if they have been at distinct risk of bleed-back from the particular exposure prone procedures performed on them by an HIV infected health care worker. Such patients should be contacted and encouraged to have pre-test discussion and HIV antibody testing.
(Paragraph 1.7)
6. The decision on whether a patient notification exercise is undertaken should be made on a case-by-case basis using risk assessment. It is anticipated that in most cases this decision will be made locally by Directors of Public Health (DsPH) of Primary Care Trusts (PCTs)/NHS boards in Scotland, supported as necessary by Regional Epidemiologists, Regional Directors of Public Health or in Scotland, the Scottish Centre for Environmental Health (SCIEH)). Where there is still uncertainty, the United Kingdom Advisory Panel for Health Care Workers Infected with Blood-borne Viruses (UKAP) may also be approached for advice.
(Paragraph 1.8)
7. HIV infected health care workers must not rely on their own assessment of the risk they pose to patients.
(Paragraph 4.6)
8. A health care worker who has any reason to believe they may have been exposed to infection with HIV, in whatever circumstances, must promptly seek and follow confidential professional advice on whether they should be tested for HIV. Failure to do so may breach the duty of care to patients.
(Paragraph 4.7)
9. Examples of how a person in the UK may have been exposed to HIV infection include if they have:
engaged in unprotected sexual intercourse between men;
shared injecting equipment whilst misusing drugs;
had unprotected heterosexual intercourse in, or with a person who had been exposed in, a country where HIV transmission through sexual intercourse between men and women is common;
engaged in invasive medical, surgical, dental or midwifery procedures in parts of the world where infection control precautions may have been inadequate;
had a significant occupational exposure to HIV infected material in any circumstances.
10. Additionally, a person who is aware that they had unprotected sexual intercourse with someone in any of the above categories may also have been exposed to HIV infection.
(Paragraph 4.8)
11. Health care workers who are infected with HIV must promptly seek appropriate expert medical and occupational health advice. If no occupational physician is available locally, consideration should be given to contacting one elsewhere. Those who perform, or may be expected to perform, exposure prone procedures must obtain further expert advice about modification or limitation of their work practices to avoid exposure prone procedures. Procedures which are thought to be exposure prone must not be performed whilst expert advice is sought.
(Paragraph 4.9)
12. If there is uncertainty whether an HIV infected worker has performed exposure prone procedures, a detailed occupational health assessment should be arranged. The UKAP can be consulted by the occupational health physician, the health care worker or a physician on their behalf if there is doubt. The health care worker's identity should not be disclosed to the UKAP.
(Paragraph 4.10)
13. If it is believed that any exposure prone procedures have been performed and that a patient notification exercise needs to be considered, the infected health care worker or their chosen representative (e.g. the occupational or HIV physician) should inform the Director of Public Health (DPH) of the relevant Primary Care Trust/NHS board in Scotland on a strictly confidential basis. The DPH or a delegated colleague (e.g. the Consultant in Communicable Disease Control (CCDC) or the Consultant for Public Health Medicine (CPHM) (CD & EH in Scotland) will in turn make an appraisal of the situation to decide whether a patient notification exercise is necessary, consulting Regional Epidemiologists, Regional Directors of Public Health or in Scotland, SCIEH, and UKAP, if necessary. The medical director of the employing trust should also be informed in confidence at this stage.
(Paragraphs 4.11 and 4.12)
14. HIV infected health care workers who do not perform exposure prone procedures but who continue to provide clinical care to patients must remain under regular medical and occupational health supervision. They should follow appropriate occupational health advice, especially if their circumstances change.
(Paragraph 4.14)
15. Health care workers who know or have good reason to believe (having taken steps to confirm the facts as far as practicable) that an HIV infected worker is practising in a way which places patients at risk, or has done so in the past, must inform an appropriate person in the infected worker's employing authority (e.g. a consultant occupational health physician) or, where appropriate, the relevant regulatory body. The DPH should also be informed in confidence. The UKAP can be asked to advise when the need for such notification is unclear. Such cases are likely to arise very rarely. Wherever possible the health care worker should be informed before information is passed to an employer or regulatory body.
(Paragraph 4.17)
16. All employers in the health care setting should ensure that new and existing staff (including agency and locum staff and visiting health care workers) are aware of this guidance and of the professional regulatory bodies' statements of ethical responsibilities, and occupational health guidance for HIV/AIDS infected health care workers.
(Paragraph 5.1)
17. Medical, dental, nursing and midwifery schools, colleges and universities should draw students' attention to this guidance and the relevant professional statements.
(Paragraph 5.2)
18. Where an employer or member of staff is aware of the health status of an infected health care worker, there is a duty to keep such information confidential.
(Paragraph 5.3)
19. Employers should assure infected health care workers that their status and rights as employees will be safeguarded so far as is practicable. Where necessary, employers should make every effort to arrange suitable alternative work and retraining opportunities, or where appropriate early retirement, for HIV infected health care workers, in accordance with good general principles of occupational health practice.
(Paragraph 5.4)
20. All matters arising from and relating to the employment of HIV infected health care workers should be co-ordinated through a specialist occupational health physician.
(Paragraph 6.1)
21. Patient safety and public confidence are paramount and dependent on the HIV infected, or potentially infected, health care worker observing their duty of self-declaration to an occupational physician. Employers should promote a climate which encourages such confidential disclosure. It is extremely important that HIV infected health care workers receive the same rights of confidentiality as any patient seeking or receiving medical care.
(Paragraph 6.7)
Patient notification exercises
22. Notification of patients identified as having been exposed to a risk of HIV infection by an infected health care worker is considered necessary:
To provide the patients with information about the nature of the risk to which they have been exposed;
To detect HIV infection, provide care, and advice on measures to prevent onward HIV transmission;
To collect valid data to augment existing estimates of the risk of HIV transmission from an infected health care worker to patients during exposure prone procedures. (
Paragraph 8.1)
23. The need for patient notification should be decided on a case-by-case using three risk
assessment criteria: evidence of possible HIV transmission, nature and history of the infected health care worker's clinical practice and other relevant considerations (e.g. evidence of poor clinical practice in relation to infection control or physical/mental impairment as a result of symptomatic HIV disease).
(Paragraph 8.4)
24. Exposure prone procedures have been classified into three levels of risk of bleed-back (categories 1-3 of increasing risk). Where there is evidence of HIV transmission from infected health care worker to patient, notification of all patients who have undergone exposure prone procedures by that health care worker should take place. In the absence of evidence of HIV transmission, all patients who have undergone category 3 procedures by an HIV infected healthcare worker should be notified. When only category 1 or 2 procedures have been carried out, patient notification will not be necessary, unless the other relevant considerations suggest that it is.
(Paragraphs 8.5-8.8 and 8.13)
25. The decision about the need for a patient notification exercise should rest with the DPH, supported as necessary by the Regional Epidemiologist and the Regional Director of Public Health or, in Scotland, SCIEH. When a patient notification exercise is to be undertaken the DPH or delegated colleague (e.g. CCDC) should inform the UKAP. If more than one Primary Care Trust is involved, it will be appropriate for the Regional Epidemiologist(s) or in Scotland, SCIEH, to become involved at this stage. If there is doubt about the need for patient notification, UKAP should be consulted.
(Paragraphs 8.15-8.16)
Confidentiality
26. Every effort should be made to avoid disclosure of the infected worker's identity, or information that would allow deductive disclosure. This may include the use of a media injunction to prevent publication or other disclosure of a worker's identity.
(Paragraph 10.2)
27. The duties of confidentiality still apply even if the infected health care worker has died, or has already been identified publicly.
(Paragraph 10.5)
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