The Patient's Right to Know the HIV Status of the Health Care Provider
The MNA recognizes its duty to provide nursing care to all citizens of the Commonwealth, including those individuals with AIDS/HIV infection while protecting the rights of individuals, including health care workers, and the welfare of the public. (1)
This duty is based on the first, third, fourth and ninth platforms of the ANA Code of Nurses and the recognition that nurses most binding duty is to do no harm to those under their care. (2)
Nurses are entitled to the same protection against discrimination under state and federal laws as all other members of society. As health care professionals, they should take all precautions against exposure to, as well as transmission of, the HIV virus by utilizing the recommendations of the DCD, OSHA and DPH.
The issues surrounding the management of the HIV-infected health care providers are complex and are made more difficult by the lack of relevant data and court precedents. The magnitude of risk of HIV transmission from health care provider to patient is still undocumented. Therefore, the questions raised regarding such risk cannot be answered by factual evidence at this time. Policy must be developed based on the interpretation of 1) clinical hospital epidemiologic/infection control experience and management of HIV-related problems in the health care setting since 1981; 2) experience with the implementation and interpretation of prior recommendations and guidelines, including those issues previously addressed by the United States Public Health Service, the Massachusetts Board of Registration in Nursing, and the Massachusetts Nurses Association, and 3) other models of blood-borne infections in the health-care setting (i.e., the HVB model).
This position paper is organized as a series of questions that address various aspects of this issue. It is based on papers written by the Association for Practitioners in Infection Control and the Society of Hospital Epidemiologists of America, Massachusetts Board of Registration in Nursing, and testimony by the American Nurses Association on Risks of Transmission of Bloodborne Pathogens to Patients During Invasive Procedure before the Center for Disease Control. The Task Force provides positions and rationale based on the above papers as well as the expert knowledge of members on the Task Force.
I. Practice Issues
- Should HIV infected Health Care Workers be allowed to practice?
- While the MNA recognizes the right of patients to be free from identified risks of infection, it also recognizes the rights of HIV positive health care providers to continue practice under the following conditions:
- Strict observation of recommended infection control procedures (Universal Precautions) that apply to all health care professionals.
- Adherence to preventative steps that protect the public from any risk of infections.
- Refraining from practices and procedures where a verified risk of transmission exists as identified by the Center for Disease Control - Department of Public Health or other public health authorities.(3)
- Health care providers who are known to have chronic transmissible blood borne infections should be advised to avoid procedures that have an epidemiological link to the transmission of HBV or other blood borne infections. (4)
- While the MNA recognizes the right of patients to be free from identified risks of infection, it also recognizes the rights of HIV positive health care providers to continue practice under the following conditions:
- Does the increasing potential for opportunistic infection associated with progression of HIV infection require further modification or restriction of an HIV-infected Health Care Provider's activities?
Most of the HIV-associated opportunistic pathogens (1) are not transmitted from person to person (e.g., Toxoplasma gondii, Mycobacterium avium complex and Cryptococcus neoformans); (2) are transmitted from person to person but all humans are repeatedly exposed and/or colonized from infancy (e.g., Pneumocystis carinii) or (3) are transmitted from person to person, but require fecal-oral exposure (Salmoneila, Cryptosporidium, Isospora) or a major break in basic aseptic technique (e.g., cytomegalovirus, herpes simplex virus). The pathogens which remain are Mycobacterium tuberculosis, varicellazoster virus (VZV), rubella virus and measles virus. Concerns have been raised both for immunosuppressed patients who might be at risk for acquiring infection from health care providers who have opportunistic infections and for immunocompromised health care providers who might acquire these infections in the course of routine patient-care activities.
Institutional policy should prohibit all health care providers with impaired cellular immunity (irrespective of the underlying cause) who are susceptible to VZV, rubella, or measles from providing direct patient care to patients with active VZV infection, rubella or measles. Implementation of these proposals requires knowledge of every health care provider's susceptibility to VZV, rubella and measles and expert counseling for health care providers who are susceptible to VZV, rubella or measles. Health-care institutions should also require of Health Care Professionals an annual PPD and control with chest x-ray where appropriate for detection of Tuberculosis.
II. Disclosure Issues
- Are there any medical settings in which HIV-infected Health Care Providers should be required to notify patients of their HIV status; and if so, what are the circumstances requiring notification?
Health care providers should not be required to disclose their HIV status to any patient except when the following condition exists:
The health care provider believes that there is a significant risk of harm to the patient because of a clearly documented exposure to health care provider's blood or other hazardous body fluid. (4) The name of the source provider does not need to be identified.
- How should a health care provider respond to a direct inquiry of his/her or a co-worker's HIV infection status?
Health care providers should be counseled to respond to questions about their own or a co-worker's health or HIV-infection status indirectly, referring further inquires to appropriate institutional management personnel. (4)
III. Testing Issues
- Should the health care provider source of a patient exposure be required to undergo HIV testing?
A health care provider who knows that he/she is the source of a significant patient exposure to his/her blood or other hazardous blood/body fluid is ethically obligated to undergo testing for infection with bloodborne pathogens. Healthcare institutions should develop specific policies to deal with such exposure for source health care professionals who refuse testing. Such policies should be formally drawn and approved by institutional attorneys and governing boards. (4)
- Should an inadvertently exposed patient be notified of the exposure?
Institutions should establish policies requiring self-reporting to the infection control program or occupational health program and to the exposed patient's primary physician of health care professional providers-to-patient blood or body fluid exposure. Irrespective of the mechanism for reporting, the exposed patient and his or her physician should be notified whenever provider-to-patient blood or blood-containing body fluid exposure has occurred. The exposed patient need not be notified of the source provider's name nor of the exact circumstances of the exposure, but should be provided enough information to understand the implication of the exposure fully. The exposed patient should be promptly notified about the exposure; subsequently be notified of the outcome of the source provider's HIV, HBV, and HCV tests; receive expert counseling regarding the implications of the event; be offered effective post exposure prophylasis; and receive appropriate long-term medical follow-up. (4)
- Should all HCWs be routinely tested for HIV infection?
Health care providers need not be routinely screened for HIV infection; however, health care providers who have community or occupational exposure to HIV should be encouraged to seek careful serologic follow-up for these exposures. (4)
- Are there any specific instances or circumstances (e.g. job classification, medical tasks, etc.) in the health-care setting in which HIV seronegativity should be considered a prerequisite; and, if so, should mandatory HIV screening programs be instituted for the relevant Health Care Providers?
Mandatory HIV screening of health care providers is not warranted. A health care professional who knows that he/she is the source of a significant patient exposure to his/her blood or hazardous blood/body fluid is ethically obligated to undergo testing for infection with bloodborne pathogens with the same support and follow-up recommended for all comparable clients. (4)
END NOTES
1. "MNA Position Paper on AIDS/HIV Infection," 1990. Massachusetts Nurses Association, Canton, Massachusetts.
2. "ANA Code of Nurses with Interpretive Statements." The American Nurses Association, Kansas City, Missouri, 1985.
3. Positive Statement on Acquired Immune Deficiency Syndrome. Massachusetts Board of Registration in Nursing, Boston, Massachusetts, 1988.
4. "Position Paper: The HIV-infected Health Care Worker." The Association for Practitioners in Infection Control, The Society of Hospital Epidemiologists of America. American Journal of Infection Control Vol 18, No. 6., Mosby Year Book, Inc., St. Louis, Missouri, 1990.
Center for Disease Control MMWR-Morbidity and Mortality Weekly Report.
January 18, 1991/Vol. 40/No. 2. "Update: Transmission of HIV Infection During an Invasive Dental Procedure - Florida." U.S. Department of Health and Human Services/Public Health Service.
BOD Approved: 6/21/91
