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13th January 2012

Department of Health consultation: The Management of HIV-infected Healthcare Workers

The Department of Health have recently launched a paper for consultation called the “Management of HIV-infected healthcare workers”, which seeks to review the restrictions in place for the work carried out by those healthcare workers who are HIV-positive. This could potentially have a significant impact on specialities such as dentistry, surgery, obstetrics, gynaecology and some aspects of midwifery and specialist nursing.

Current national guidance restricts HIV-infected healthcare workers from performing “exposure prone procedures”, so that patients are protected from the possible risk of infection.  Evidence supplied by the Tripartite Working Group demonstrated that such risks are extremely low and negligible in certain cases.  Only four instances of HIV transmission from a HIV-infected healthcare worker to a patient has ever been discovered worldwide.  No cases have ever been found in the UK, even though between 1988 and 2008 nearly 10,000 patients had been tested for HIV as a part of 30 patient notification exercises.  The risk of HIV transmission to a patient having the most invasive type of exposure prone procedure from a healthworker (irrespective of HIV status), is estimated to be between 1 in 1,672,000 and 1 in 4,680,000.  There is a greater risk of the healthcare worker contracting HIV from a patient, than vice versa.

Three conditions are necessary for a HIV-infected healthcare worker to pose a risk of transmission to patients:

  1. The healthcare worker must have the infectious virus circulating in their bloodstream;
  2. The healthcare worker must be injured or have a medical condition that provides some other source of direct exposure to infected blood or body fluids;
  3. The injury mechanism or medical condition must present an opportunity for the healthcare worker’s blood or body fluids to come into direct contact with the patient’s mucous membranes, wound or traumatized tissue.

The tripartite working group concluded that the risks can be minimised still further by combination antiretroviral drug therapy (cART), where “the plasma viral load is suppressed to a very low or undetectable level”.  The recommendations of the working group are:

  • HIV-infected healthcare workers should be permitted to perform exposure prone procedures if they are on cART and have a plasma viral load suppressed consistently to very low or undetectable levels, i.e. below 200 copies/ml;
  • HIV-infected healthcare workers should demonstrate a sustained response to cART before starting or resuming exposure prone procedures and should be subject to viral load testing every three months while continuing to perform such procedures;
  • HIV-infected healthcare workers who wish to perform exposure prone procedures whilst on cART should be under the joint supervision of a consultant in occupational medicine and their treating physician;
  • Any HIV-infected HCW who fails to comply with monitoring arrangements, or whose plasma viral load rises significantly above 200 copies/ml (i.e. to more than 1000 copies/ml), should be restricted from performing exposure prone procedures until their viral load returns to being stably below 200 copies/ml.”

The response to the consultation and the follow-up by the Department of Health will have a significant impact on dental practices and other relevant healthcare professions, regarding the employment and use of HIV-infected healthcare workers.  The consultation will close on the 9th March 2012.  It is hoped that the Department of Health will seize the initiative and help to undo some of the stigma attached to HIV-infected healthworkers, especially when it is considered that a patient is more likely to be struck by lightning than receive HIV in such circumstances!

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