The Department of Health has opened a consultation on
possible changes to its policy on the employment of people with HIV. The
current ban on people with HIV performing specific procedures in surgery,
dentistry and gynaecology may be lifted, so that staff who are taking
antiretroviral therapy and have a viral load below 200 copies/ml could work in
Implementation of the proposal will, in part, depend on the
responses received during the public consultation that is open until 9 March
2012. Patient safety in the NHS is a sensitive political issue and if public
discussion is not informed by scientific evidence, the proposals could be
Current UK policy is for a total ban on HIV-positive
healthcare workers performing ‘exposure-prone procedures’. As a result, a
number of medical jobs are not open to people with HIV and the consequences for
someone diagnosed in the middle of their career can be devastating.
An exposure-prone procedure is one in which injury to the
healthcare worker could result in the worker’s blood contaminating the patient’s
open tissues. These procedures involve a combination of sharp objects and the
worker’s hands being in a body cavity. Surgery is the most obvious example, but
many dental procedures are also considered ‘exposure-prone’.
Only a few other developed countries (including Australia, Ireland and
Italy) have a policy as restrictive as that of the UK. It is more common for
the management of an HIV-positive healthcare worker to be determined on a
case-by-case basis. This is the situation in Austria, Belgium, Canada, France,
New Zealand and Sweden, for example.
A current court case, in which a dentist with HIV is
claiming the current ban is discriminatory and unlawful, helps explains why the
government is considering the change.
A working group of experts examined the evidence on the risk
of transmission occurring in healthcare settings, especially when patients have
been treated by an HIV-positive health worker. Internationally, there have only
been four cases of transmission, none of them in the UK. In the United States, testing of 22,171 patients who had been
treated by 51 different HIV-positive workers, including surgeons, obstetricians
and dentists, did not identify any new HIV infections.
During some of the less invasive ‘exposure-prone procedures’
(such as a local anaesthetic injection or a routine tooth extraction), the
experts consider the transmission risk to be “negligible”. During the most
invasive procedures (such as a caesarean section or open cardiac surgery), they
consider the risk to be “extremely low”.
But the experts consider that the risk of HIV transmission
will vary, depending on the infectiousness of the health worker, as measured by
They therefore recommend that HIV-positive workers should be
allowed to perform exposure-prone procedures as long as:
- They are taking combination antiretroviral
- Their viral load is consistently below 200
copies/ml (tests taken every three months)
- They are under the joint supervision of a
consultant in occupational medicine and their usual doctor.
The recommendations therefore open the possibility of
individuals taking HIV treatment for occupational health reasons, when it would
not otherwise be recommended.
Workers whose viral load rebounded or who ceased to comply
with the testing requirements would be asked not to perform exposure-prone
procedures until the situation was resolved.
Based on the prevalence of HIV in the England and the number
of NHS employees who perform exposure-prone procedures, the experts estimate
that the measures could affect around 110 HIV-positive workers (including those
with undiagnosed infection).
England’s Chief Medical Officer, Dame Sally Davies,
commented: "We need to ensure that the guidelines and restrictions imposed
are evidence-based and achieve a fair balance between patient safety and the
rights and responsibilities of healthcare workers with HIV. This consultation
will seek wide views on the expert advice and whether it should be
The chairman of the Expert Advisory Group on AIDS, Professor
Brian Gazzard, said: "Our careful review of the evidence suggests that the
current restrictions on healthcare workers with HIV are now out of step with
evidence about the minimal risk of transmission of infection to patients and
policies in most other countries. This risk can be reduced even further if the
healthcare worker is taking effective drug therapy for HIV and being monitored
by HIV and occupational health specialists."
As healthcare is a responsibility of the
devolved administrations in the United Kingdom, there are likely to be parallel
consultations in the four countries. England and Scotland have already issued
consultation documents, both of which are open until 9 March 2012.The consultation in Wales is open until 23 February 2012.