Occupational Exposure to HIV Infection and its Ethics and Legal Issues

RESUMO

A. Exposure Nosocomial HIV transmission is a particular worry for many doctors; medical students and nurses who work in low income countries such as Uganda. Firstly; the prevalence of HIV infection among the patients we care for in poor countries is high. Secondary; many health workers; such as medical students; interns and new nurses are often relatively experienced - their technical skills may not be well practiced and hence they are likely to be exposed to blood and other body fluids. Thirdly; many developing countries with a high prevalence of HIV lack the resources to implement universal precautions adequately. Finally; poor or inadequate equipment and facilities are more often encountered in developing countries; especially in Africa south of Sahara and can increase the risks of exposure to HIV infection. These occupational risks are clearly additional to the risks from unprotected sex; for which separate preventive measures apply. although the risk of infection per exposure may be low; the comulative risk with repeat incidents icnreases and sero-conversion does occur (1). Devastating personal and professional consequences may then ensue. Example of the Problem: A few years ago a team of doctors reviewed nosocomial HIV exposure at a rural district hospital in Southern Africa. In this hospital 25of patients attending for antenatal care were positive for HIV. Most medical staff are relatively hunior doctors; including those from Europe who spend a year or more doing general medical duties; including surgical and obstetrics; that regularly expose them to blood and other body fluids. In a recent period of 10 months; five out of eight doctors experienced a needlestick injury while treating a patient infected with HIV. This is eqivalent to 0.75 exposures per doctor per year. All incidents were considered severe as each broke the doctor's skin; involved a bloody needle and drew the health worker's own blood. Three doctors were exposed while using faulty or incorrect eqquipment for an operation or resuscitation. Extent of the Problem: This frequency of exposure is by no means unusual. In parts of West Africa; a group of indigenous doctors reported an annual average of four needlestick injuries. A group of Dutch doctors working in Africa reported an annual average of five needlestick injuries (2). In one Zambian district hospital it was estimated that each general surgeon experience three parenteral exposures each year; and that the risk of acquiring HIV infection through work was 1.5over five years(3). These are minimum estimates of risk because needlestick injuries and other exposures to body fluids are under reported and their frequency is higher among less experienced practitioners. How many African Health professionals work in settings where the prevalence of HIV is high; or for how long; is unknown. However; by way of example; Uganda has in active medical services tens of thousands of nurses and midwives; a thousand doctors; eight thousand clinical officers and tens of thousands of other health professionals. They are all working in settings where the prevalence of HIV is high. The estimated annual neddlestick injury to each surgeon is ten; and the risk of acquiring HIV infection through work may be as high as 5-10over five years. B. Ethical Issues Under current guidelines health workers who think that they may be HIV positive are advised to informe their employers. If there is considered to be no risk to patients the person concerned can continue working. However; most workers who are HIV positive in developing countries do not inform their employers for fear of losing their jobs without compensation even if they contracted HIV in the line of their duty. Doctors however; especially surgeons; ar eunder ethical obligation to protect their patients. doctors must put the safety of their patients foremost. When confronted with the information which suggests a doctor has been at risk of HIV infection; he/she must inform someone of authority; such as Medical Council; Senior Colleague or employer. Failure to disclose the information is a betrayal of patients trust; and undermines the trust placed by the public in the Medical profession. In 1994; a British doctor; an ENT Surgeon at Gartnavel General Hospital in Glasgow; by the name George Browning; discovered that he was HIV positive patient. he made a public announcement soon afterwards. The GMC deliberated over his case; and decided to allow him return to the operating theatre. However; GMC stated that patients to be operated on by Professor Browning will be asked to sign a consent form stating that they know that he is HIV positive; and anyone can ask for another surgeon if he or she wishes. C. Legal Issues (i) Taking Responsibility Are governments and other organisations that recruit and employ health workers under legal obligations to provide cover for occupational hazards such as needlestick injuries? What formal and legal responsibilities do medical schools have for clinical students? How may a student prove that he did not acquire the infection through sexual intercourse? In britain; for example; anyone exposed to HIV in a work setting would expect to have immediate access to prophylaxis. (ii) Cost of protection If post-exposure prophylaxis is to be provided; who pays for the drugs? A dose of 1000mgm Zidovudine per day for four weeks; a regimen shown to be effective; costs $500. Now both Britain and the US recommend four weeks of triple therapy (Zedovuline 200mgm tds; lamivudine 140mgm BD; and indinavir 800mgm tds); at a cost of $680