Chapter 5
Health Care and HIV/AIDS

Of the adults reported with AIDS in the United States through to December 31, 2001, 23,951 had been employed in health care representing 5.1% of the 469,850 AIDS cases reported to the CDC for whom occupational information was known.  The type of job is known for 94% of these individuals as follows:  1,384 physicians, 88 surgeons, 3,856 nurses, 378 dental workers, 317 paramedics, 3,086 technicians, 1,050 therapists, and 6,365 health aids.  The remainder are maintenance workers, administrative staff, etc. (CDC, Surveillance of Healthcare Personnel, 2001).

Healthcare workers whose practices are modified because of their HIV infection status should, whenever possible, be provided opportunities to continue appropriate patient-care activities.  Career counseling and job retraining should be encouraged to promote the continued use of their talents, knowledge and skills.

Health care workers during the course of providing care can also find themselves at significant risk for exposure to HIV transmission.  The average risk of transmission of HIV is approximately 0.3 % (95% CI 0.2-0.5%) after a percutaneous or needle stick exposure and approximately 0.09% (95% CI 0.006-0.5%) after a mucous membrane exposure (MMWR  2001;50 RR-11). The risks from non-intact skin exposure and exposure to body fluids other than blood are felt to be considerably less. As of June 2000, there have been only 56 documented cases of HIV seroconversion from occupational exposure and an additional 138 possible cases.  Most were percutaneous exposures to infected blood.

Preventive Strategies and Infection Control

Recommendations for the prevention of transmission of HIV in healthcare settings have been made by the CDC that emphasize adherence to standard precautions.  Standard precautions are intended to prevent parenteral, mucous membrane, and non-intact skin exposures of health care workers to blood-borne pathogens. They apply to blood and other fluids containing visible blood as blood is the single most important source of HIV and other blood-borne pathogens in the occupational setting.  Healthcare personnel should follow infection control precautions at all times. 

These precautions include:

• the routine use of barriers such as gloves, gowns, masks, or goggles when anticipating contact with blood or body fluids with visible blood
• washing hands and other skin surfaces immediately after contact with blood or body fluids, and
• the careful handling and disposal of sharp instruments during and after use

Body fluids considered to be potentially infectious include cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids.  Semen and vaginal secretions have been implicated in sexual transmission of HIV but not in occupational transmission. 

Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they contain blood.  In situations such as emergencies wherein differentiation between fluid types is difficult, if not impossible, all body fluids should be treated as potentially infectious.

Hands and other skin surfaces should be washed immediately and thoroughly with soap and water if contaminated with blood, other body fluids, or potentially contaminated articles.  Use alcohol based antiseptic hand cleanser or wash hands after removing gloves and with each patient contact.

Safety devices have been developed to help prevent needle stick injuries. Needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand.  If recapping is necessary, use a one-handed technique or recapping block device.

Institutions should provide all healthcare personnel with appropriate in-service or education regarding infection control and safety and should establish procedures for monitoring compliance with infection-control policies.

Management of Occupational Exposure to HIV

If a healthcare worker is exposed to potentially infected blood or body fluids, the wound should be immediately washed or the mucous membrane flushed.  Reporting and evaluation of potential exposure to HIV should be reported within hours as initiation of post-exposure prophylaxis (PEP) is felt to be most effective is administered in the first 24-36 hours after exposure.  The healthcare personnel should be tested for HIV at baseline.

Determine the risk severity of exposure.  Percutaneous exposure to larger quantity of blood or visibly bloody fluid, or instruments that have been placed directly in a vein or artery, or resulting in deep injuries confer higher risk.  The source of exposure should also be assessed when able.  HIV infected sources in the terminal stage of their illness likely have higher viral load and risk for transmission.

When the HIV status of the source is unknown, determine the presence of risk factors or the presence of findings that make HIV likely.  Test the source whenever possible using rapid HIV tests.  If the source is unknown, consider PEP in settings where exposure to HIV-infected persons is likely such as drug treatment facilities or STD centers.

PEP with either a 2- or 3-drug antiretroviral regimen as outlined in the CDC recommendations (MMWR  2001;50 RR-11) is to be given for 28 days.  The HCW is counseled on the potential side and monitored for drug toxicity.  Perform HIV antibody testing at 6 weeks, 3 months and 6 months after exposure.

Risk for hepatitis B and C exposure should also be assessed and addressed.

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