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AIDS/HIV Infected Health Care Workers: Guidance on the Management of Infected Health Care Workers and Patient Notification

1. INTRODUCTION

1.1 These guidelines apply to all health care workers in the NHS and private sectors, including visiting health care workers in any health care setting and students in training for whom there may be implications for future career options.

1.2 The guidelines are intended to replace the version issued in December 1998, AIDS/HIV Infected Health Care Workers: Guidance on the Management of Infected Health Care Workers and Patient Notification. They reflect changes in NHS structures, experience of patient notification exercises and the recommendations of a joint working group of the Expert Advisory Group on AIDS (EAGA) and the United Kingdom Advisory Panel for Health Care Workers Infected with Blood-Borne Viruses (UKAP), which has recently reviewed the policy for notifying patients exposed to HIV infected health care workers.

1.3 This guidance continues to endorse the ethical guidance in the statements from the professional regulatory bodies, clarifies the duties of HIV infected health care workers, their medical advisers and employers, and outlines the procedures which should be followed if a patient notification exercise is being considered.

1.4 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.

1.5 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.

1.6 The circumstances in which HIV could be transmitted from an infected 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. This is described as "bleed-back" in this guidance. HIV infected health care workers must not perform any exposure prone procedures. The majority of health care workers do not perform exposure prone procedures.

1.7 The EAGA recommends that, as far as is practicable, patients should only be notified if they have been at a distinct risk of bleed-back from the particular exposure prone procedures performed on them by an HIV infected worker. Such patients should be contacted and encouraged to have pre-test discussion and HIV antibody testing.

1.8 The decision on whether a patient notification exercise is undertaken should be made on a case-by-case basis using the risk assessment criteria developed by the EAGA/UKAP Working Group. 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 board in Scotland, supported as necessary by Regional Epidemiologists, Regional Directors of Public Health, or in Scotland, SCIEH. Where there is still uncertainty, the UKAP may also be approached for advice.

1.9 The recommendations in this guidance reflect the need to protect patients, to retain public confidence and to safeguard the confidentiality and employment rights of HIV infected health care workers.

2. CURRENT ESTIMATES OF THE RISK OF TRANSMISSION

2.1 Documented cases of hepatitis B and hepatitis C infections have occurred in patients operated on by hepatitis B or C infected health care workers. It is plausible that HIV could be transmitted under similar circumstances, although the risk of HIV transmission has been shown to be considerably less than for hepatitis B or hepatitis C following needlestick injuries.

2.2 Worldwide, there have been two reports of possible transmissions of HIV from infected health care workers performing exposure prone procedures: a French orthopaedic surgeon and a Florida dentist. Although genetic relatedness was demonstrated in both cases, only in the case of the French orthopaedic surgeon was the route of transmission clear. ^{1, 2}

2.3 All other retrospective studies worldwide of patients exposed to the potential risk of transmission of HIV during exposure prone procedures have failed to identify any patients who have become infected by this route.

2.4 The data available from patient notification exercises supports the conclusion that the overall risk of transmission of HIV from infected health care workers to patients is very low. Between 1988 and 2001 in the UK, there were 22 patient notification exercises. However, there was no detectable transmission of HIV from an infected health care worker to a patient despite about 7,000 patients having been tested.

2.5 The Public Health Laboratory Service's (PHLS) Communicable Disease Surveillance Centre (CDSC) and, in Scotland, SCIEH actively follow-up newly diagnosed HIV infections to establish the likely route of transmission. There have been no inexplicable infections, which might otherwise have been potentially linked to exposure prone procedures.

2.6 The evidence indicates that there is a far greater risk of transmission of HIV from infected patients to health care workers than from infected workers to patients. Up to June 1999, there had been 102 cases worldwide of health care workers in whom seroconversion was documented after occupational exposure to HIV from patients. Five of these were cases in which transmission occurred in the UK. ³

2.7 The Department of Health, EAGA and UKAP will continue to evaluate the epidemiological evidence on the risks of transmission, informed by results from properly documented patient notification exercises when these are considered necessary.

3. GENERAL PRINCIPLES OF BLOOD-BORNE VIRUS INFECTION CONTROL

AND EXPOSURE PRONE PROCEDURES

3.1 The Health Departments published guidance for clinical health care workers on protection against infection with blood-borne viruses in 1998 ( see box). ⁴ This guidance should be followed to minimise the risk of blood-borne virus transmission to health care workers from patients. The measures recommended will also minimise the risk of transmission from infected workers to patients, and from patient to patient.

3.2 All breaches of the skin or epithelia by sharp instruments are, by definition, invasive. Most clinical procedures, including many which are invasive, do not provide an opportunity for the blood of the health care worker to come into contact with the patient's open tissues. Provided the general measures to prevent occupational transmission of blood-borne viruses are adhered to scrupulously at all times most clinical procedures pose no risk of transmission of HIV from an infected health care worker to a patient, and can safely be performed.

3.3 Those procedures where an opportunity for health care worker to patient transmission of HIV does exist are described as exposure prone and must not be performed by a health care worker who is HIV infected.

3.4 Exposure prone procedures are those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient's open tissues to the blood of the worker (bleed-back). These include procedures where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. However, other situations, such as pre-hospital trauma care and care of patients where the risk of biting is predictable (e.g. such as with a disturbed and violent patient or a patient having an epileptic fit) should be avoided by health care workers restricted from performing exposure prone procedures.

3.5 Procedures where the hands and fingertips of the worker are visible and outside the patient's body at all times, and internal examinations or procedures that do not involve possible injury to the worker's gloved hands from sharp instruments and/or tissues, are considered not to be exposure prone provided routine infection control procedures are adhered to at all times. Examples of such procedures include:

• taking blood (venepuncture);

• setting up and maintaining intravenous lines or central lines (provided any skin tunnelling procedure used for the latter is performed in a non-exposure prone manner);

• minor surface suturing;

• the incision of external abscesses;

• routine vaginal or rectal examinations;

• simple endoscopic procedures.

Examples of UKAP's advice on which procedures are and are not exposure prone are attached at Annex A.

3.6 The final decision about the type of work that may be undertaken by an infected health care worker should be made on an individual basis, in conjunction with a specialist occupational physician, taking into account the specific circumstances including working practices of the worker concerned. The occupational physician may wish to consult the UKAP.

3.7 The decision whether an HIV infected worker should continue to perform a procedure which itself is not exposure prone should take into account the risk of complications arising which might necessitate the performance of an exposure prone procedure. Only reasonably predictable complications need to be considered in this context.

3.8 The likelihood of injury to the health care worker and consequent possible risk to the patient depends on a number of factors which include not only the type and circumstances of the procedure, but also the skill and fitness to practise of the health care worker and patient circumstances (e.g. if the patient is restless or agitated).

4. THE DUTIES AND OBLIGATIONS OF HEALTH CARE WORKERS WHO ARE OR MAY BE INFECTED WITH HIV

4.1 The current statements of the General Medical Council, General Dental Council and the Nursing and Midwifery Council about the ethical responsibilities of health care workers towards their patients are set out at Annex B. These responsibilities are equally applicable to all other professional groups not covered by these regulatory bodies.

4.2 All doctors, dentists, nurses, midwives, health visitors and other professionals who have direct clinical care of patients, have a duty to keep themselves informed and updated on the codes of professional conduct and guidelines on HIV infection laid down by their regulatory bodies and any relevant guidance issued by the Health Departments.

4.3 In addition, students should be made aware of the implications of these statements and of the contents of this guidance ( see also Paragraphs 1.1 and 5.2)

4.4 All health care workers are under ethical and legal duties to protect the health and safety of their patients. Under the Health and Safety at Work etc. Act 1974, health care workers who are employees have a legal duty to take reasonable care for the health and safety of themselves and of others, such as colleagues and patients, and to co-operate with their employer in health and safety matters.

4.5 Self-employed health care workers have general duties to conduct their work so that they and others are not exposed to health and safety risks. The Employment Medical Advisory Service of the Health and Safety Executive (HSE) is able to act as a liaison point between health care employers and their employees, and HSE. It may also be approached by infected health care workers wishing to seek advice on health and safety issues.

4.6 HIV infected health care workers must not rely on their own assessment of the risk they pose to patients.

4.7 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.

4.8 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 transmission of HIV 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.

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.

4.9 HIV infected health care workers must promptly seek and follow appropriate expert medical and occupational health advice. If there is no occupational health physician available locally, consideration should be given to contacting one elsewhere. Those who perform or who may perform exposure prone procedures must obtain further expert advice about modification or limitation of their working practices to avoid exposure prone procedures. Procedures which are thought to be exposure prone must not be performed whilst expert advice is sought ( see Section 6).

4.10 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 (any correspondence must be anonymised or pseudonyms used).

4.10 If it is believed that any exposure prone procedures have been performed and that a patient notification exercise needs to be considered, then the infected health care worker or their chosen representative (e.g. the occupational health physician or the HIV physician) should inform the DPH of the relevant PCT/NHS Board in Scotland on a strictly confidential basis.

4.12 The DPH or a delegated colleague (e.g. Consultant in Communicable Disease Control (CCDC) or CPHM in Scotland) will in turn make an appraisal of the situation to decide whether a patient notification exercise is warranted, consulting Regional Epidemiologists, Regional Directors of Public Health or in Scotland, SCIEH and UKAP, if necessary. The medical director of an employing trust should also be informed in confidence at this stage ( see Section 8).

4.13 The health care worker, the occupational health physician or the HIV physician should not make the decision about whether a patient notification exercise needs to be considered.

4.14 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 ( see Section 6).

4.15 Once any health care worker has symptomatic HIV disease, closer and more frequent occupational health supervision is necessary. As well as providing support to the worker, the aim of this is to detect at the earliest opportunity any physical or psychological impairment which may render a worker unfit to practise, or may place their health at risk.

4.16 HIV infected health care workers applying for new posts should complete health questionnaires honestly. HIV infection is a medical condition about which an occupational physician should be informed, verbally if preferred. Details will remain confidential to the occupational health department, as for other medical conditions disclosed in confidence to occupational health practitioners ( see Paragraphs 6.7 and 6.8).

4.17 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 health care worker's employing authority (e.g. an 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.

5. THE RESPONSIBILITIES OF EMPLOYERS AND COMMISSIONING BODIES

5.1 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. This may include issuing regular reminders. Commissioners may wish to stipulate this when placing service agreements with NHS Trusts. This advice is also applicable to the private sector. Under the Control of Substances Hazardous to Health (COSHH) Regulations 1999, employees must receive suitable and sufficient information, instruction and training on the risks and precautions to be taken. ⁴

5.2 Medical, dental, nursing and midwifery schools, colleges and universities should draw students' attention to this guidance and the relevant professional statements. Each training establishment should identify a nominated officer with whom students may discuss their concerns in confidence. In addition, all students should be appropriately trained in procedures and precautions to minimise the risk of occupational blood-borne virus transmission. All these issues should be addressed before there is clinical contact with patients.

5.3 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 any such information confidential. They are not legally entitled to disclose the information unless that individual consents, or in exceptional circumstances ( see Section 10). A decision to disclose without consent should be carefully weighed as authorities or persons taking such action may be required to justify their decision.

5.4 Employers should assure infected health care workers that their status and rights as employees will be safeguarded so far as practicable. Where necessary, employers should make every effort to arrange suitable alternative work and retraining opportunities, or where appropriate, early retirement for HIV infected workers, in accordance with good general principles of occupational health practice.

5.5 The Disability Discrimination Act 1995 makes it unlawful to discriminate against disabled persons including those with symptomatic AIDS or HIV infection in any area of employment, unless the employer has justification because of a material and substantial reason. The restriction of such a worker for the purpose of protecting patients from risk of infection, such as the requirement to refrain from performing exposure prone procedures, would justify discrimination. However the employer who knows that the worker is disabled has a duty to make reasonable adjustment, e.g. by moving the worker to a post, if available, where exposure prone procedures could be avoided. Asymptomatic HIV infection does not currently bring the worker within the protection of the Disability Discrimination Act 1995.

5.6 The NHS Injury Benefits Scheme (or HPSS Injury Benefits Scheme in Northern Ireland) provides temporary or permanent benefits for all NHS employees who lose remuneration because of an injury or disease attributable to their NHS employment. The scheme is also available to general medical and dental practitioners working in the NHS. Under the terms of the scheme it must be established whether on balance of probabilities the injury or disease was acquired during the course of NHS work.

5.7 Although HIV is not a prescribed disease under the Social Security Acts, health care workers who have acquired HIV infection because of exposure to HIV infected material in the workplace may be able to claim Industrial Injuries Disablement Benefit where there has been an accident arising out of and in the course of employment, e.g. a needlestick injury.

6. THE ROLE AND RESPONSIBILITIES OF THE OCCUPATIONAL HEALTH SERVICE AND HIV PHYSICIANS

6.1 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.

6.2 The HIV physician providing the necessary regular care to an infected worker should liaise with the occupational health physician and preferably they should jointly manage the case.

6.3 Occupational health services which do not employ a specialist occupational physician should refer individuals to such a physician in another unit. The Association of National Health Service Occupational Physicians (ANHOPS) has issued guidance to its members and has given a list of specialist occupational physicians who can be contacted by those working in occupational medicine in the field ( see Annex D). The close involvement of occupational health departments in developing local procedures for managing HIV infected health care workers is strongly recommended.

6.4 If such arrangements do not exist, the Faculty of Occupational Medicine or ANHOPS will also put independent contractors and other non-NHS staff in touch with a specialist occupational health physician. Alternatively, the physician looking after the worker may contact the UKAP for advice.

6.5 Whilst the occupational health physician has responsibility for occupational medical management and assessment, if a physician is not immediately available, some infected health care workers may initially seek advice from an occupational health nurse. The nurse should make every effort to arrange for the health care worker to see the occupational health physician as soon as possible. If necessary the occupational health nurse should seek confidential advice directly from the UKAP. As for any other referral to the UKAP, identification of the worker should be avoided.

6.6 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 that 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. Occupational health practitioners, who work within strict guidelines on confidentiality, have a key role in this process, since they are able to act as an advocate for the health care worker and adviser to the employing authority. They should adopt a proactive role in helping health care workers to assess if they have been at risk of HIV infection and encourage them to be tested for HIV if appropriate ( see Paragraphs 4.7-4.9).

6.7 Occupational health records are held separately from other hospital notes and can be accessed only by occupational health practitioners, who are obliged ethically and professionally not to release records or information without the consent of the individual. Conversely, occupational health practitioners do not have access to hospital notes. There are occasions when an employer may need to be advised that a change in duties should take place, but HIV status itself normally would not be disclosed without the health care worker's consent. However it may be necessary in the public interest for the employer and the DPH to have access to confidential information where patients are, or may have been, at risk.

6.8 Occupational physicians are well placed to act as advocates for the worker on issues of retraining and redeployment, or, if indicated, medical retirement. Occupational health departments have a key role to play in developing local policies for the management of infected health care workers' future employment.

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