In July 1990 a Florida dentist infected six patients during invasive dental procedures. A French orthopaedic surgeon, doing a long orthopaedic operation, has also transmitted HIV to a patient.

There may have been specific circumstances in the dental practice which led to the infections. Investigators are uncertain as to how exactly transmission occurred. Some researchers are uncertain as to whether the dentist really was the source of infection for his five patients, although the US Centers for Disease Control conducted an extensive investigation.

In spite of the risk of transmission of HIV from a health care worker to a patient being considered remote, the Department of Health has issued guidance on the management of HIV-positive healthcare workers and on the notification of patients treated by HIV–positive health care workers. The Department of Health's position is reflected in the statements of healthcare workers' professional bodies (i.e. the General Medical Council, the General Dental Council and the UKCC).

Healthcare workers are expected to:

• Seek medical advice and HIV antibody testing if they believe themselves to have been at risk of HIV infection.
• If they are HIV-positive they are to seek medical and occupational advice from a physician.
• If they perform 'exposure-prone procedures' (see below for definition), they must cease any further such work immediately and seek advice from an occupational health physician.
• If exposure prone procedures have been performed, the health care worker must inform the local Director of Public Health or arrange for the physician acting on his/her behalf to do it. This information will be treated on a strictly confidential basis.
• If they have not performed exposure-prone procedures, they must remain under regular medical and occupational health supervision and receive appropriate occupational health advice if their circumstances change.

Physicians/Occupational Health Practitioners treating health care workers with HIV are expected to:

• Inform the appropriate regulatory body and the Director of Public Health if they are aware that an infected healthcare worker has not sought or followed advice to modify their practice and/or are continuing to perform exposure prone procedures.

Employers are expected to:

• Ensure that all staff, including students, are aware of the professional regulatory bodies' statements of ethical responsibilities and occupational guidance for HIV-positive healthcare workers.
• Ensure that medical information and records and the identity of the healthcare worker is kept confidential. (However, the duty of confidentiality is not absolute and there may be rare circumstances where disclosure of information is in the public interest. Disclosure of information without consent is acceptable only in exceptional circumstances, although the guidance specifies no mechanism by which the employer can be held accountable for any such disclosure).
• Arrange suitable alternative work or training for HIV-positive staff or, where appropriate, early retirement.

The Director of Public Health is expected to:

• Adhere to the same duties of confidentiality as described above.
• Decide whether patients should be notified that they have undergone an exposure prone procedure at the hands of an HIV-positive healthcare worker. The guidance recommends that a notification exercise should be undertaken where the infected worker was the sole or main person performing the exposure prone procedure. However, the individual circumstances of each case must be considered before a public notification exercise is decided upon and the Director of Public Health should discuss their decision with the UK Advisory Panel before proceeding.

How far back Directors of Public Health should go in notifying former patients of the healthcare worker is likely to depend on how confidently the date of infection can be established. Where a clinical history cannot be obtained or if the healthcare worker has AIDS or has died, the Department of Health recommends notifying all patients who have undergone exposure-prone procedures in the past ten years.

What are exposure-prone procedures and who do the guidelines affect?

Exposure-prone procedures are those 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. 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”.

Although a normal vaginal delivery is not an exposure prone procedure,

“When undertaking a vaginal delivery an infected healthcare worker must not perform procedures involving the use of sharp instruments such as infiltrating local anaesthetic, or suturing of a tear or episiotomy, since fingertips may not be visible at all times and the risk of injury to the worker is greater. Neither can they perform an instrumental delivery requiring forceps or suction if infiltration of local anaesthetic or internal suturing is required. In practice, this means that an infected healthcare worker may only undertake a vaginal delivery if it is certain that a second midwife or doctor will also be present who is able to undertake all such operative interventions as might arise during the course of delivery”.

The following procedures would not be considered exposure-prone as long as routine infection control procedures are adhered to at all times:

“Procedures where the hands or fingertips of the worker are visible and outside the patient's body at all times, and internal examinations or procedures that do not require the use of sharp instruments... Examples of such procedures include the taking of blood, setting up and maintaining IV lines, minor surface suturing, the incision of abscesses or uncomplicated endoscopies”.

Patient notification of healthcare worker's HIV status-policy update

In December 2001 the Department of Health announced a new policy on the action to be taken whenever a healthcare worker is found to be HIV-positive. The new policy is based on advice from the Expert Advisory Group on AIDS and the UK Advisory Panel on Health Care Workers Infected with Blood Borne Viruses.

This new policy states that the risk of HIV transmission to patients will be assessed on a case by case basis using a criteria based framework. The extent of the patient notification exercise will depend on the level of risk of exposure. This may mean that in some instances there will no patient notification exercise, or it is limited in scope.

The decision to change the policy was reached in the light of the fact that there has never been a case of transmission of HIV from an infected health care worker to a patient in the UK detected, even though 22 extensive look back exercises involving tens of thousands of patients have been undertaken. This step has been taken in an effort to avoid unnecessary anxiety to patients and means that the policy is now more in line with that of the rest of the world.

Until this policy came into force all patients have been notified regardless of their level of risk. Under the new guidance, all patients that are notified will be offered pre-test discussion and an HIV antibody test.

HIV testing new NHS recruits

On the 2^nd January 2003, the Department of Health announced that all new recruits to the NHS who will be involved in exposure-prone procedures will be tested for HIV and hepatitis C. The draft guidance is now available at the Department of Health website at http://www.doh.gov.uk/.

If you think you may be HIV-positive and are a healthcare worker

If you think you might be HIV-positive the guidance states that you must seek medical advice and, if appropriate, an HIV test. Failure to do this is regarded as a potential breach in the duty of care to patients. If you are already aware of your HIV status, the chances are that you will also have taken some steps towards evaluating your professional practice and judging what risk is posed to patients. If you have not already informed a designated occupational health physician, you need to consider the consequences of this breach of guidelines on your future employment. Think what might happen if your confidentiality is subsequently breached, or you become symptomatic and unable to work. The most serious consequence of a failure to disclose is that you may be liable to disciplinary action from your employer.

Needlestick injuries, HIV infection and employment

Needlestick injuries raise a number of troubling issues for health care workers and managers, despite the rarity with which workers are actually infected through this route. Refer to the Department of Health’s guidelines for the latest information. http://www.doh.gov.uk/.

Guidelines for employers

• The UKC provides advice, training, information and support for all employers, trade union members or employees who may be infected or affected by HIV and AIDS. They also offer a wide range of services for people living with HIV from career guidance to skills training. (etc. – whatever you want to write). See http://www.ukcoalition.org/.
• National AIDS Trust is the leading independent policy and campaigning voice on HIV and AIDS. They produce materials aimed at both employers and employees. See http://www.nat.org.uk/
• Employers Forum on Disability provide general advice and guidance on disability in the workplace. Publications include Employers Briefing Paper 13 – A practical guide to employment adjustments for people with HIV. See http://www.employers-forum.co.uk/.
• Health Development Agency (HDA) produces a range of publications on HIV and AIDS. HIV and AIDS at Work: How to set up an HIV/AIDS policy is aimed at employers, trade unions and health professionals. Some HDA publications are aimed at specific occupations, for example, seafarers. Some information in relation to HIV is available on their website http://www.hda-online.org.uk/.
• The Disability Rights Commission (DRC) is an independent body, established by Act of Parliament to eliminate discrimination against disabled people and promote equality of opportunity. The DDA take on individual disability discrimination cases, including HIV related cases; provides information about the law, rights, information and publications for businesses and services, policy and campaigns. The can be contacted by post: DRC Helpline, FREEPOST, MID02164 Stratford upon Avon, CV37 9BR. Helpline: 08457 622 633. Textphone: 08457 622 644. Fax: 08457 778 878 or Website: http://www.drc-gb.org/

HIV employment and other issues abroad

The UK NGO AIDS Consortium is a networking organisation for charities sending employees to developing countries. The Consortium has published two booklets called HIV/AIDS & Overseas Employment. One booklet is for employers, the other for employees. The booklets are published and available from the Health Development Agency (HDA). For more enquires about working abroad contact at UK NGO AIDS Consortium for the Third World, Fenner Brockway House, 37–39 Great Guildford Street, London SE1 OES. Tel: 020 7401 8231.

The CBI produce a booklet called AIDS & Overseas Business Travel available from the CBI, Centre Point, New Oxford Street, London WC1.

Health & safety/first aid at work

The Health & Safety Executive and the Department of Health AIDS Unit provide written guidelines for various occupations, especially in the National Health Service.

Advice on first aid at work is available from The British Red Cross Society, the St. John's Ambulance Brigade or in Scotland, the St. Andrew's Association.

Trade unions and professional associations

The TUC offers a training pack and a joint statement on AIDS (with the CBI and ACAS). Available from: TUC Publications, Congress House, Great Russell Street, London WC1B.

Some unions have issued their own guidelines and codes of good practice. UNISON, for example, has produced several comprehensive publications on HIV and AIDS.

Many unions, however, have produced guidelines which address issues specifically to do with the industry or sectors they represent: some of the guidelines, therefore, do not necessarily carry information on the broader issues on HIV and AIDS or about safer sex.

Information for legal advisors

The publishers Butterworths have just produced two books which give guidance to legal advises about HIV and about sexual orientation:

Advising Clients with HIV/AIDS - A Guide for Lawyers edited by Avrom Sherr and Isabel Manley, concentrates on the legal implications of a client being HIV-positive or of developing AIDS. The book covers all issues which a client will need advice on, including disclosing one's status, criminal and civil liability, access to medical records and right to treatment, discrimination and employment issues, arranging financial affairs and living wills, family issues such as custody and guardianship of children, the rights and education of HIV-infected children and access to social services such as housing and welfare benefits. Published by Butterworths. ISBN 0 406 92931 9.

Advising Gay and Lesbian Clients - A guide for Lawyers, various contributors. The book provides detailed and practical coverage of issues of specific concern to lesbian and gay clients including in and outside employment, immigration issues, arranging financial affairs, inheritance tax planning and making wills, cohabitation, the family home, custody disputes, adopting and fostering children, donor insemination and the criminal law as it affects gay men. Published by Butterworths. ISBN 0 406 90303 4

Disability Discrimination Claims - An Adviser's Handbook by Catherine Casserley and Bela Gor. The book concentrate on the practicalities of bringing disability discrimination cases before the employment tribunal. Published by Jordans. ISBN 0 85308 642 7

Referral for clients

National organisations giving legal advice to individuals who have employment problems, including discrimination, related to their HIV status are:

Terence Higgins Trust,
54 Grays Inn Road, London, WC1X 8JU
Tel: 020 7831 0330
info@tht.org.uk
http://www.tht.org.uk/

UK Coalition of people Living with HIV and AIDS
Tel: 0207564 2180
http://www.ukcoalition.org/

Acas
Tel:08457 47 47 47
http://www.acas.org.uk/