Rules for infected health care workers criticized
Rules for infected health care workers criticized
Current guidelines have hurt workers, critics say
Responding to pressure from groups such as the Presidential Advisory Council on HIV/ AIDS, the Centers for Disease Control and Prevention will re-evaluate its guidelines for HIV-positive health care workers, which have been criticized for promoting discrimination and ruining careers.
More than five years since it published guidelines for how providers should respond to infected health care workers, the CDC plans to convene a panel of experts to evaluate the scientific and operational issues related to its recommendations. Once the working group comes up with several options such as keeping the guidelines intact, entirely revising them, or revising parts of them the CDC will bring together its Advisory Committee for HIV/AIDS and its Hospital Infection Control and Prevention Advisory Committee as early as March to evaluate them.
"The concern is that the guidelines haven’t protected anybody, and that they have, in fact, had an adverse impact on health care workers they have lost their jobs," says Rob Janssen, MD, deputy director of the CDC’s division of HIV/AIDS surveillance.
In its annual report released in December, the Presidential Advisory Council on HIV/AIDS noted that, after much debate and discussion, the CDC had agreed to have external experts review "its current discredited and discriminatory guidelines."
The most outspoken group opposing the guidelines is The Gay and Lesbian Medical Association in San Francisco, whose Medical Expertise Retention Program has evaluated the guidelines and counseled infected health care workers.
"For the last six years I have taken more than 1,700 calls from infected health care workers, and I can tell you the CDC guidelines have had a devastating impact on them," says the program’s director, Naphtali Offen. "They have seen their careers ruined, or at minimum they have to live in fear the other shoe will drop if they keep it [their infection] to themselves."
Other AIDS experts, however, question the need for the CDC to spend more resources on an issue that impacts only a small portion of the HIV-positive population. "All of a sudden it is the focus of a two-day meeting for what has got to be a minuscule part of the epidemic," said Walter Schlech, MD, an infection control officer at Victoria General Hospital in Halifax, Nova Scotia, and a member of the CDC’s Advisory Committee on HIV and STD Prevention.
Created during emotional times
The guidelines, critics contend, were developed in the emotionally and politically charged aftermath of a 1991 CDC investigation showing that HIV-positive Florida dentist David Acer had infected six patients. Congress subsequently passed legislation requiring states to adopt regulations "equivalent" to those of the CDC. The extent and impact of the state laws, however, have not been thoroughly evaluated by the CDC. At the same time, new research on the risks of provider-to-patient transmission has been published and should be considered along with other contemporary factors, such as the impact of triple-drug therapy on the infectiousness of HIV-positive health care workers, Janssen said.
Since the Acer case, only one case of provider-to-patient HIV transmission has been documented; last year, French medical authorities reported that an untreated French surgeon with late-stage HIV disease had infected a patient during a lengthy surgery. (See AIDS Alert, March 1997, p. 31.) At the same time, there have been 52 documented cases of patients passing HIV to medical workers, primarily through needlestick injuries.
Nonetheless, the widespread publicity of the Acer case continues to instill fear in the public consciousness, AIDS experts note. Against this backdrop, HIV-positive health care workers have been subject to what many medical professionals call an unworkable and discriminatory set of guidelines, which include requirements that health care workers who perform exposure-prone procedures be tested for HIV and inform their patients if they test positive.
It is clear they need to be revised’
"The CDC guidelines weren’t bad at the time they came out," says Neil Schram, MD, an internist at Southern California Permanente Medical Group in Harbor City, CA, and member of the CDC Advisory Committee on HIV and STD Prevention. "However, the way they have been implemented has been bad, and it is clear they need to be revised."
Under the current guidelines, state health officials were urged to set up expert review panels to determine on a case-by-case basis whether infected health care workers could continue to work in their current capacity. The CDC also established a controversial list of exposure-prone medical procedures that infected health care workers could not perform.
However, the CDC has little information on how many health care workers have lost their jobs or been forced into other careers, Offen tells AIDS Alert. From anecdotal reports, many HIV-positive health care worker have lost their jobs, often because employers were not willing to risk liability suits and negative publicity, he says. Equally disturbing, the guidelines have forced health care workers to keep their infection secret, or worse, avoid knowing their HIV status.
"I am always shocked, particularly this late in the epidemic, to hear about physicians who find out they are positive when they come down with PCP," he notes. "They say, I knew I might be positive but I just didn’t want to have that knowledge because if I did, in my state, I would have to report myself.’"
The Gay and Lesbian Medical Association is calling for an end to health care worker disclosure of HIV status. "What we are asking for is good privacy, confidentiality that the witch hunt be over," Offen says.
The association notes that each year nearly 80,000 patients reportedly die in the United States from non-HIV related infections accidentally acquired while hospitalized, and yet no similar restrictions are required to prevent these cases.
Short of an outright repeal of the guidelines, the association charges the CDC to issue a scientific update stating that:
• It is no longer justified that HIV-positive health care workers inform patients of their status.
• No procedure should be considered HIV "exposure-prone."
• No health care worker should be restricted from practice unless posing a "significant risk," as defined by the Americans With Disabilities Act.
Legal challenges to ADA protections
The CDC review comes at a time when protections against HIV-positive people are being questioned in court. The U.S. Supreme Court will soon be hearing its first AIDS case, involving a dentist who refused to treat an HIV-positive patient unless the treatment took place in a local hospital operating room, at the patient’s expense. The court’s decision may resolve uncertainty over whether the Americans With Disabilities Act protects people with asymptomatic HIV infection.
"I have been very disappointed at how the courts have dealt with this issue," Lawrence Gostin, JD, professor of law at Georgetown University, told the Advisory Committee. "They really have almost excluded health care workers from the protection of ADA, not by saying they are not disabled but by saying there is significant risk [of them infecting patients]," he said.
Because the future of infected health care workers will depend more on legal wrangling and political sentiment than on science, Gostin and others said it was important that medical groups such as the American Medical Association state their positions clearly and strongly. The AMA will tackle the issue of infected health care workers at its June meeting, says an AMA spokesperson. Recently, the Society for Healthcare Epidemiology of America changed its 1990 guidelines on HIV-positive health care workers, allowing infected workers to perform invasive procedures.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.