Department of Health Management of HIV Infected Healthcare Workers Consultation March 2012
Introduction 1.1 Terrence Higgins Trust (THT) is the UK s leading HIV and sexual health charity, working with over 50,000 people in England, Scotland and Wales every year. We provide a variety of services across England ranging from support for people living with or affected by HIV: counselling, group work and social care, to prevention and health promotion initiatives including HIV and STI testing. 1.2 THT welcomes this consultation and supports the position of the tripartite working group on management of healthcare workers who are living with HIV. We agree that changes to the current policy are warranted based on the successful suppression of viral load that Combination Anti-Retroviral Therapy now achieves for individuals. We believe that the current policy of prohibiting healthcare workers living with HIV from performing EPP is overly restrictive and therefore runs the risk of being discriminative towards people living with HIV. It also means that highly trained professionals are being lost to the NHS unnecessarily. 1.3 We support the level of consultation that is being undertaken on this issue across the UK. However, we would urge cooperation between Governments to ensure a consistent approach to this issue across England, Wales, Scotland and Northern Ireland. Consultation Question 1. Do you agree with the tripartite working group s assessment of the risk of HIV transmission from an infected healthcare worker to a patient during exposure prone procedures? 2.1 The fact that there have never been any HIV transmissions from healthcare workers living with HIV recorded in the UK demonstrates that the risks involved are extremely low and that universal infection control procedures are strong in the NHS. We appreciate that modelling of risk in these circumstances is difficult. However, we believe that the Tripartite Working Group s work provides a fair assessment which includes very strong weighting towards patient safety. The actual risk of HIV infection from an infected healthcare worker is in reality likely to be far less than outlined by the triparite group s findings. Consultation Question 2. Do you have any comments on the assessment of overall risk of HIV transmission to a patient having an exposure prone procedure of the most invasive type from healthcare worker? Do you consider it more likely that healthcare workers who think that they are at risk of infection may come forward for HIV testing, if the tripartite working group s recommendations were implemented, and do you have any evidence of this? 3.1 There is considerable evidence which suggests that one of the most significant barriers to HIV testing is stigma, in particular the fear of negative social consequences from an HIV diagnosis 12. Whilst there is an absence of specific 1 ECDC TECHNICAL REPORT, HIV testing: Increasing uptake and effectiveness in the European Union, Evidence synthesis for Guidance on HIV testing, Dec 2010 (page 7) http://ecdc.europa.eu/en/publications/publications/101129_ter_hiv_testing_evidence.pdf 2 Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England: Barriers to HIV testing, Fakoya, et al. http://www.nice.org.uk/nicemedia/live/13417/53679/53679.pdf 2
research in relation to healthcare workers at risk or living with HIV, it is entirely reasonable to assume that people working in the health sector who believe themselves to have been at risk of HIV could feel such stigma or fears more acutely, as the prospect of losing their job could add an additional dimension of anxiety. The financial and social consequences of losing your career and livelihood are likely to weigh heavily on the mind of any healthcare worker who considers themselves to have been at risk and is thinking about testing. 3.2 THT is aware of anecdotal evidence in the UK where professionals, such as dentists, living with HIV have refused to disclose their status as they feel that they are currently being treated very unfairly. The Welsh Assembly s Equality of Opportunity Committee heard evidence of self regulation from the British Dental Association during its Inquiry into Discrimination against People Living with HIV by Healthcare Professionals and Providers 3.3 We believe that altering the current policy would address such grievances and would promote a more supportive and open culture in which healthcare professionals living with or at risk of HIV could feel more relaxed and confident in accessing occupational support and testing. We believe that this would benefit healthcare workers and would also cut potential risks to patients by reducing the number of undiagnosed healthcare workers living with HIV and by mitigating against any individual attempts to self manage occupational issues without support. 3.4 The British Dental Association has publicly indicated that it would like to see changes to the regulations on dentists living with HIV. They have outlined their support for the Bejing declaration from the 2009 World Workshop on Oral Health& Disease in AIDS 3. Participants from over 30 countries at this meeting concluded that with proper safety procedures, there is no real risk of transmission and that people with HIV should be allowed to work as dentists provided their own health is supervised and that standard infection control is observed 4. Indeed, dentists with HIV can now practise in more than twenty countries including the USA, Israel and France. 3.5 Another potential benefit from this change in policy could be a reduction within the NHS of HIV related stigma. Many people living with HIV report receiving poor treatment within the NHS on account of their HIV status 5. Nearly 20% of people surveyed by Sigma in its national survey of people with diagnosed HIV (2007-2008) reported having experienced discrimination in the last year from doctors or other health or care professionals. 6 3.6 Particular concerns have been expressed in relation to the treatment of people living with HIV by dentistry services. We are aware of numerous examples of individuals reporting being subjected to undue / excess precautions, such as double gloves and only being able to take the last appointment of the day in order that 3 Dentists with HIV face 'unfair' treatment : http://www.guardian.co.uk/society/2011/may/17/dentists-hiv-unfair-treatment 4 6th World Workshop on Oral Health and Disease in AIDS, Beijing Declaration 2009 5 Elford J et al. HIV-related discrimination reported by people living with HIV in London, UK. AIDS and Behaviour (in press), 2008. http://journals.cambridge.org/action/displayabstract?frompage=online&aid=6161484 6 What do you need? 2007-2008 Findings from a national survey of people with diagnosed HIV Weatherburn et al. (pages 98-99) http://www.sigmaresearch.org.uk/files/report2009b.pdf 3
dental instruments could be sterilised afterwards or outright refusal to provide a service. THT believes that it is not unreasonable to assume that the discriminatory and prohibitive approach to people living with HIV that it sometimes observed in dentistry services is to some degree informed by the fact that dentists have an exaggerated perception of risk based on the contention that they would no longer to be able to practice if they contracted the virus personally. Consultation Question 3: Are the tripartite working group s main recommendations supported by the available evidence about risk? 4.1 THT is confident that the tripartite working group has carried out a thorough investigation of the evidence. We believe that their recommendations are proportionate and warranted. We also consider that the group has prioritised patient safety and has based its recommendations on a weighted interpretation of the evidence around risk. Consultation Question 4: Does the suggested implementation framework strike an appropriate balance between protecting patient safety and acknowledging the rights and responsibilities of HIV infected healthcare workers, and is it feasible? 5.1 Given the relatively small numbers of healthcare workers living with HIV in the UK, we believe that the framework outlined is appropriate and entirely manageable. We would support adoption of the tripartite group s recommendations in this area. However, we would welcome further consideration and clarification of the following points: 5.2 The fourth paragraph on page 12 of the documents states that healthcare workers living with HIV would not be expected to disclose their status to patients. However, the paragraph also states in brackets that this would depend on the invasiveness of the procedure. We are unclear as to what this means and feel that if professionals are required to disclose their status to any patients (except in exposure cases) then this could entirely undermine the purpose of the policy. We would urge further consideration of this statement and would welcome more detail on what procedures, if any, would warrant sufficient risk to require advance disclosure to a patient. 5.3 We would welcome further detail on how a healthcare worker s confidentiality would be managed in the event of an exposure incident, risk assessment or patient notification exercise. For example, what would the procedure be for identifying another member of the clinical team to undertake a risk assessment and how would confidentiality be ensured in that event? Similarly, if a healthcare worker has fully cooperated with risk management processes, but a patient notification exercise is still required, what processes will be put in place to safeguard the confidentiality of that worker, particularly in light of potential press attention. We would suggest that legal intervention may be required in this instance. 4
5.4 Finally, we would welcome more detail on the suggestion of a national database. We do have a number of confidentiality concerns regarding such a database and how it could potentially be misused. The suggestion is also that this database sit with the HPA which is being disbanded. We require further detail before we can fully support this recommendation. Consultation Question 5. What adjustments will occupational health services need to make to support HIV infected healthcare workers affected by these recommendations? 6.1 Clear confidentiality and referral processes and policies will need to be drawn up to support implementation of the policy. These should outline responsibilities of all staff involved including the healthcare worker living with HIV and occupational health staff. They should also detail the procedures that need to be followed in the evident of an exposure incident, risk assessment or patient notification exercise. Thought should be given as to whether national guidance is needed or whether local polices will be sufficient. 6.2 We would also recommend that training on HIV awareness (including HIV related stigma and actual transmission risks) should be given to all occupational health and human resources staff working in the NHS. Consideration should be given as to whether there is benefit to expanding such training on a local basis. Consultation Question 6. Is referral of all cases of HIV infected healthcare workers infected with HIV who wish to perform exposure prone procedures whilst on combination antiretroviral drug therapy (cart) to UKAP necessary to ensure consistency in the application of the policy and to help promote best practice? If so, for how long should this continue? 7.1 The final paragraph of page 13 states that: Cases where an HIV infected healthcare worker s viral load rises above the recommended viral load threshold should be notified to UKAP, and their advice sought about the need to do a patient notification exercise. However, it goes on to state that it would remain a local decision as to whether a patient notification exercise would need to be carried out. We consider that this paragraph is unclear in its intention. For example, would UKAP need to be informed if the healthcare worker s viral load had increase above the threshold but they had not undertaken any recent EPP? 7.2 As we outlined in 6.1 we think that UKAP may have a role in developing implementation guidelines. Referral of cases may be useful initially for development and review of such guidelines and best practice. However, we are not convinced that it would be necessary to refer every case to a national body over the longer term. 5
Consultation Question 7. Do you agree that, if the tripartite working group s recommendations are implemented, patient notification exercises should only routinely take place in connection with untreated HIV infected healthcare workers, as advised in current national guidance, unless a healthcare worker on cart may have put patients at risk of infection e.g. because of an increase in viral load? 8.1 We agree for the most part with this suggestion. However, we would welcome clarification of the point we outline in 7.1. Also, we would suggest that patient notification should only take place if viral load has increased above the identified threshold. It would be entirely counter-productive for unnecessary patient notification exercises to take place if there has not been any real risk of infection. Consultation Question 8. Is national monitoring of policy implementation at the NHS frontline necessary? If so, how should it be done most effectively and proportionately, and what might be the cost implications? Is it appropriate or feasible for local occupational health services to submit local information about HIV infected healthcare workers to the Health Protection Agency to allow national surveillance of policy? 9.1 As previously stated we would welcome further clarification of the role that national monitoring would play. We are unsure as to the benefit of national monitoring and surveillance in the absence of national implementation guidance and the plans for the majority of decision making to take place at local level. 9.2 The HPA is also set to be disbanded, so we would welcome clarification of whether Public Health England would now take on this role. Consultation Question 9: Does the estimate of the number of healthcare workers who may be affected by the policy seem reasonable? Is there further information that consultees can provide and/or are there further sources of information that the Department should consult? 10.1 We agree that the estimate of healthcare workers who may be affected by the policy is reasonable. Consultation Question 10: Does the consultation impact assessment accurately reflect the possible costs and benefits of the policy, were it to be implemented? Is there further information that consultees can provide and/or are there further sources of information that the Department should consult? Consultation Question 11: Does the draft equality screening assessment adequately assess equality issues in this context? Is there further information that consultees can provide and/or are there further sources of information that the Department should consult which may be relevant? 11.1 We are satisfied with the Equality Impact Assessments as outlined. 6