A Positive Response for HIV-Infected Healthcare Workers
The Government's proposals to modernize HIV rules in the UK, to take effect from April 2014, represent a positive step for healthcare workers (HCWs) infected with the virus. HIV-positive staff will now be permitted to carry out Exposure-Prone Procedures (EPPs), provided that they meet strict regulatory criteria, and the ban on home-testing kits will be lifted in an effort to encourage early diagnosis.
The UK currently maintains some of the strictest rules in the world on this issue, with many of the laws formulated in the 1980s, and predicated on the scientific and sociological understanding of AIDS at that time. Campaigners argue that this stance has reinforced the stigma surrounding the disease, discouraged diagnosis and hence put patients at risk.
Factoring in evidence of the increasing sophistication of combination Antiretroviral Therapy (cART), as well as statistical risk assessments and epidemiological research, the new rules are intended to reflect the very scant risks that infected staff now pose to patients.
If the findings of the Government's consultation hold true, there should be very little need for recourse to the law of clinical negligence for new cases of HIV transmission to patients. Laurence Vick, senior partner in Michelmores' Clinical Negligence team, approved of the way in which the changes had been formulated. 'We support the cautious but progressive approach that the Government has taken,' he said. 'If they can bring in an evidence-based set of changes, which help to promote diagnosis of medical staff and don't stigmatize those who are infected, that's good progress. Patient safety comes first, though, and they will need to continue being extremely careful.'
There have only been four reported incidents worldwide of HCWs infecting patients with HIV - none in the UK - and, given that cART has been found to reduce perinatal infection rates (between mother and child) to 1 in 100, experts are confident that the chances of infection during surgery or other medical treatment would be as remote as 1 in 833,000, even in the most invasive procedures. There would never be zero risk of infection, however.
EPPs carry the following definition from the Department of Health:
...where there is a risk that injury to the worker may result in exposure of the patient's open tissues to the blood of the worker. These procedures include those where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (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.
This includes surgery, obstetrics, gynaecology, and some elements of midwifery, such as repairing perineal tears. Most dental procedures are defined as EPPs; even taking impressions (moulds) is held to be an EPP (although not on edentulous, or toothless, patients).
The Monitoring Process
To be able to carry out EPPs, an HCW must be on effective cART drug treatment, such that their viral load is reduced to undetectable levels. Combination Antiretroviral Therapy (cART) suppresses the HIV virus, interfering with its development in the body and lessening the chances of transmission. HCWs will need to submit to monitoring by an occupational health worker, with check-ups at 3-month intervals. If their viral load rises significantly above the stipulated level, they will be prevented from carrying out EPPs. Confidential advice should be available to HCWs found to be infected, and they will be expected to comply with the stipulations absolutely.
Professional Perspective: the Wider World of Blood Products
Laurence Vick emphasises that the monitoring process would be key to maintaining standards and public confidence, and that comprehensive records should be kept to demonstrate due diligence. However, he does not identify HCW infection as the salient issue in transmission of blood-borne diseases to patients. 'Speaking from my experience running infection claims, contaminated blood products like blood plasma can have an appalling impact,' he said. 'It isn't just the effect on the patient, being diagnosed with a chronic and potentially fatal disease - a lot of the shock comes from the breach of trust, particularly where there are questions about the sourcing of the blood.
'You've also got to realise,' he added, 'that there can be hundreds, maybe thousands of people exposed, so it can become a huge issue.' Laurence and his team at Michelmores represented clients who had been affected by the blood products scandal that began in the 1970s and 80s, in which as many as 5000 people were exposed to HIV, hepatitis C and, in some cases, the brain disease CJD. It was estimated that, by the time the case reached the UK High Court in 2010, nearly half of those infected had died, with the survivors left fighting for adequate compensation. The scandal was described by Lord Robert Winston as the worst disaster in the history of the NHS.
The tragedy of the tainted blood incident may yet be recapitulated. All blood plasma in the UK is collected from donors in the US, in an effort to prevent potential contamination with CJD from UK donors. The company which supplies the blood, Plasma Resources UK, has been all but sold to the American private equity firm Bain Capital, with the UK Government retaining only a 20% share. Experience has shown that market forces and blood supply make for an uneasy mix, and many commentators are wary that patient interests may be compromised. While the Government's proposals to relax restrictions on HIV positive healthcare workers seem like good sense, the wider landscape of blood-borne disease remains an uncertain place.
Once the changes to the HIV rules have been enacted, there will continue to be small risks of transmission to patients, although the Department of Health estimates that the chances of a patient being infected are similar to their likelihood of being struck by lightning. It should also be noted that patient-to-HWC transmission is far more common than vice versa (there have been 5 reported cases of patients infecting HWCs with HIV in the UK, compared to none in the other direction). Guidelines on informing patients who have had an EPP carried out by a professional with any of the above conditions will remain essentially unchanged, with patient-notification exercises carried out on a case-by-case basis.
The barring of HCWs from carrying out invasive procedures continues to apply to those infected with hepatitis B and C; in terms of transmission, these diseases pose notably greater risk than HIV, although there has still not been a case of a patient contracting hepatitis C in the UK since 1999.