Health care workers who are HIV-positive should not face restrictions on their practice as no procedures have proven to be "exposure-prone" related to transmission of the virus, the Arlington Heights, IL-based American College of Occupational and Environmental Medicine (ACOEM) stated in a recently released guideline.
"You can look back at 20 years of the epidemic, during a time when there have been many HIV-positive surgeons practicing surgery," says Mark Russi, MD, MPH, chair of ACOEM’s occupational infectious disease committee. "There has been one case of a surgeon transmitting HIV, if you leave out the cluster [of cases related to] the Florida dentist.
"With no more evidence than [that] of transmission of HIV from health care workers to patients, it’s difficult to justify restricting them from carrying out their profession," he says, who is associate professor of medicine and public health at the Yale University School of Medicine and director of occupational health at Yale-New Haven (CT) hospital. Instead, ACOEM recommends that HIV-infected health care workers who perform invasive procedures should double-glove and "minimize to the extent possible digital palpation of needle tips and blind probing in poorly visualized or highly confined anatomic sites."
Exposure-prone hard to define
In a case that is still largely unexplained, six patients of an HIV-infected Florida dentist acquired the disease in the late 1980s.1 In 1992, a French orthopedic surgeon transmitted HIV to a patient on whom he had performed a 10-hour surgical procedure.2 Yet as of June 2001, there have been more than 23,000 health care workers with HIV in the United States, according to data from the Centers for Disease Control and Prevention (CDC). Such a low risk of transmission makes it impossible to identify procedures that are particularly "exposure-prone," as the CDC advised in its HIV guideline released in 1991,3 Russi says.
The CDC said that procedures were exposure-prone if "a needle tip was digitally palpated in a body cavity, or . . . a health care worker’s fingers and a needle or other sharp instrument or object are simultaneously present in a poorly visualized or highly confined anatomic site." However, the agency never issued any further parameters or lists of exposure-prone procedures. ACOEM’s position is "within the intent and spirit of the CDC guideline," Russi says. "We have another 10 years of experience, and there’s only been one transmission."
ACOEM did note that a greater risk of transmission exists for health care workers who are hepatitis B e-antigen positive. Further, in light of recent reports of transmission of hepatitis C from health care workers to patients, ACOEM will consider a separate position statement on that disease, Russi says. "It’s clearly an area that we need to address," he says.
In other HIV-related issues, ACOEM stated:
• Employees with HIV infection or AIDS qualify for protection under the Americans with Disabilities Act (ADA) and the Family and Medical Leave Act (FMLA). Under the ADA, employers must provide reasonable accommodations and are prohibited from discriminating against employees because of their disability. The FMLA provides a 12-month unpaid leave to employees with "serious health conditions" who have at least one year of service.
• Although ACOEM doesn’t support restrictions on HIV-positive health care workers, it noted that courts have not considered such policies to be discriminatory. In May, the U.S. Supreme Court declined to hear the appeal of a dental hygienist who sued under the ADA when he was reassigned to a lower-paying clerical position after his employer learned he was HIV-infected. In Waddell v. Valley Forge Dental Association, the 11th Circuit Court of Appeals upheld a dismissal of his case, stating that it did not constitute discrimination because of the potential risk to patients.4
• A source patient may harbor resistance to antiretroviral medication, complicating the decision about post-exposure prophylaxis. While treatment should begin as quickly as possible, the medication may be adjusted after consultation with infectious disease experts, ACOEM says. Because of possible toxic side effects, those on prophylaxis regimens should be closely monitored.
• Occupational health physicians should be involved in the development of policies regarding AIDS and HIV in the workplace and should design educational programs.
References
1. Centers for Disease Control and Prevention. Update: Transmission of HIV infection during an invasive dental procedure — Florida. MMWR 1991; 40:21-33.
2. Lot F, Seguier J-C, Fegueux S, et al. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med 1999; 130:1-6.
3. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40(RR08):1-9.
4. Waddell v. Valley Forge, No. 00-14896, 11th U.S. Circuit (Dec. 21, 2001).
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