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HIV and the health professions: universal precautions are required

By Sandhya Srinivasan

Protection of health personnel and patients from HIV transmission is difficult in a healthcare setting in which nurses may be permitted only two pairs of gloves a day and needles are reused after a perfunctory wash. The answer is not special precautions for HIV-positive patients, but universal precautions for all health workers who come into contact with blood and body fluids

Both healthcare personnel and patients have expressed concern about the risk of HIV transmission in the healthcare setting. HIV is most commonly transmitted through the sexual route. However, there is also a risk of infection through blood transfusion, medical procedures and needle-stick injury. The health system's response to this risk has created a huge controversy.

HIV is a fragile virus and can be easily destroyed with routine sterilisation procedures. These should be standard practice in all health services. Doctors, nurses, wardboys, technicians and others who come into contact with all blood and body fluids should be protected against various infections including HIV. This requires standard protective equipment such as gloves when handling blood or body fluids, and training in the proper way to handle and dispose of needles and other sharps. Such precautions protect healthcare workers against all blood-borne infections including HIV, Hepatitis B and Hepatitis C. Finally, if despite all these precautions staff are exposed to HIV through, for example, a needle-stick injury, post-exposure prophylaxis (PEP) with a course of anti-retroviral drugs reduces the chances of infection actually setting in.

Protecting both health personnel and patients from HIV transmission in the healthcare setting will create an environment supporting rational treatment of people regardless of their HIV status.

The ground realities

Unfortunately, it is felt that few health service providers, whether public hospitals or private nursing homes, provide adequate protective equipment to their staff.

There are innumerable horror stories. Government nurses have spoken of being provided two pairs of gloves for use on patients through the entire day. Under-equipped primary health centres are known to re-use needles after a perfunctory wash.

The situation is better than it was a few years ago. Dr Dilip Karnad, head of the medical intensive care unit of KEM Hospital, Mumbai, notes that some well-run public institutions do their best to protect patients and healthcare workers despite limited funds. They test patients suspected of being HIV-positive, after taking their consent, and follow extra precautions when a patient is known to be HIV-positive. Government hospitals offer post-exposure prophylaxis to their staff exposed to HIV infection at work. However, they cannot afford to implement universal precautions, the most comprehensive method of preventing transmission of HIV.

Further, if some tertiary government hospitals offer post-exposure prophylaxis, this is not necessarily assured to all hospital staff, nor is it necessarily available in the smaller and more remote healthcare facilities.

Municipal and state government hospitals can face shortages of everything from drugs to disposables, equipment to staff. So the dean of one state government hospital found telephone lines cut because the bills hadn't been paid for months. In such circumstances drugs and simple reusables can be in short supply. If the situation is believed to be tolerable in some tertiary care hospitals it is certainly not so good in peripheral hospitals and primary health centres.

Government cutbacks in recent years have aggravated an already difficult situation. Even in private hospitals, nurses have described how poor training increases the risk of needle-stick injury. In an article on the occupational risk of blood-borne infections, Shreedevi Balachandran refers to case records demonstrating the importance of proper training. One injury occurred because a staff member walked across a room holding a used but uncapped needle in her hand. In another case, the doctor drew blood for testing but forgot the needle on the patient's bed and a nurse got injured while changing the sheets. In a third, the nurse recapped the needle in a hurry and was injured. (Shreedevi Balachandran. 'Nurses and the risk of blood-borne infection'. Issues in Medical Ethics, October-December 2002).

Since anti-retroviral drugs are expensive, hospital administrations may not provide them for post-exposure prophylaxis as part of an occupational risk protection package. This situation can make staff more reluctant to provide care to people known to be HIV-positive.

The consequences for patient care

There have been a number of newspaper reports that patients known to be positive are 'referred' from government hospitals to other hospitals. There have been reports of HIV-positive women giving birth to their children on the roadside because the hospital refused entry. The scenario may have improved marginally in the last few years. People are not tested routinely for HIV and there may be less overt discrimination. Still, the absence of a strong government stand on the subject coincides with the overall disintegration of government health services. The result: there are many reports of unsystematic and callous treatment. For example, all cases may be referred to the hospital-appointed 'HIV expert' who orders a few tests and prescribes some symptomatic treatment. People have complained that there is no proper counselling. But a person diagnosed as HIV-positive requires a more comprehensive approach.

Private hospitals can afford to provide protective equipment and train their staff but unfortunately few have done so. It is well-known that private hospitals all over the country routinely test all in-patients for HIV, without their knowledge or consent. Those who test positive are either refused care outright, or are told they will have to pay more to cover the cost of 'special' protective equipment. Dr Sanjay Nagral recalled that a patient with HIV who needed an endoscopy had to pay Rs 20,000 instead of the Rs 5,000 that he would otherwise have paid. Those scheduled for surgery will find they are moved to the end of the working day, and after their surgery all equipment is thoroughly sterilised. The patients of doctors specialising in HIV-related care are reportedly kept at a distance even if there is no evidence of outright negligent treatment.

There are a number of irrational practices here. First, a positive test can be wrong, and a negative test is no assurance that the patient is in fact HIV-negative; she or he could just be in the window period between infection and the antibodies showing up in the blood. Special cautions with the known HIV-positive, instead of universal precautions, will miss the risk of infection from a person with HIV in the window period. Second, conducting special sterilisation procedures for people with HIV implies that the regular sterilisation procedures are improperly done.

However, the private sector is largely unaccountable to the public. It is often forced into action only by the threat of legal action or worse. Current pressure on the private sector to treat people regardless of their HIV status seems to have got them fighting with their backs to the wall.

HIV, healthcare and the courts

In this context, a number of legislative efforts will be worth watching. Proposed legislation in Delhi and Maharashtra includes penal provisions against healthcare personnel who refuse treatment to people with HIV. Writ petitions have been filed in the Delhi High Court (Lawyers' Collective for the Delhi Network of Positive People) and the Supreme Court (Colin Gonsalves for the Voluntary Health Association of Punjab) on people's right to healthcare regardless of their HIV status. The petitions also ask that people with HIV be given access to treatment for AIDS. Colin Gonsalves has noted that 10 of the 12 WHO-recommended drugs to fight AIDS were manufactured by Indian companies and these were available to AIDS patients through government programmes in other parts of the world. Anand Grover of the Lawyers' Collective notes that treatment for HIV was more than just prescribing drugs; it should include informed consent of the patient within a holistic framework. The Lawyers' Collective has also asked for guidelines to protect medical personnel from infections.

InfoChange News & Features, August 2003